Healthcare business graph and Medical examination and businessman analyzing data and growth chart on blured background

Refer to these definitions and descriptors as you complete the Essential Assessment Questions

1. Types of wounds:
• Venous ulcer ?, Arterial ulcer ?, Pressure ulcer ?, Diabetic/neuropathic ulcer ?, Burn/blister wound ?
2. Anatomical location
3. Wound dimensions:
• Length x width x depth in centimeters
  (Head to toe = Length, Side to side = width, Straight down = depth)

View Diagram


• Undermining & tunneling

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4. Extent of tissue loss:
• Non-pressure ulcers: full or partial loss
• Pressure ulcers: staging
5. Tissue present: type and percentage of each present
• Granulating (red granular base)

• Clean, non-granulating

• Hypertrophic Granulation (overgrowth of granulation tissue, sits above skin level)

• Slough

• Eschar

• Epithelial (pink epithelium)

6. Exudate: type and amount present
• Serous, Sanguineous, Serosanguineous, Tan, Yellow, Brown, Green, Clear (thick or thin), Purulent
7. Oder after cleaning with NS/wound cleanser/water
8. Wound edges:
• Open vs. Closed/Rolled

• Distinct vs. indistinct
9. Periwound skin:
• Macerated (white or grey “water-logged” skin)

• Intact
• Erythema
• Candida
• Epidermal stripping