Assessment, Diagnosis, and Documentation of Wounds
Start with etiology, then measure
Wound assessment is a reproducible process, not a snapshot. The first question is always what kind of wound is this - pressure, venous, arterial, neuropathic, surgical, atypical - because etiology drives every later decision. Then document objective parameters: anatomic location, length × width × depth, percentage of each tissue type in the bed (granulation, slough, eschar, epithelial), wound edges, undermining and tunneling, exudate amount and character, periwound skin, odor, pain, and signs of infection or biofilm. Pair the local assessment with a systemic one: perfusion (pulses, ankle-brachial index, capillary refill), sensation (10-g monofilament), mobility, nutrition, and comorbidities.
Documentation standards
Entries must be dated, timed, signed, objective, measurable, and comparable over time. Replace vague phrases like "healing well" with measurable change (area, depth, tissue percentages). Reassessment occurs at defined intervals and with any change in status.
Traps that appear in questions
- Confusing undermining (tissue loss under intact edges, charted by clock position) with tunneling (a track extending outward from the wound).
- Assigning a pressure injury stage to a venous, arterial, or diabetic foot wound - staging applies only to pressure injuries.
- Measuring length side-to-side instead of head-to-toe.
- Relying on a superficial swab instead of tissue biopsy when deep infection is suspected.
- Charting only the wound and omitting the patient: pain, function, goals, and risk factors.
Rule of thumb
Length runs 12 o'clock to 6 o'clock (head-to-toe), width 3 to 9 o'clock, depth at the deepest point with a moistened cotton swab held perpendicular. Chart undermining as, for example, "2 cm from 3 to 6 o'clock."