Assessment and Terminology: Critical Issues in Wound Care

Cynthia A. Worley


Dermatology Nursing. 2004;16(5) 


"Wisdom begins in wonder." - Socrates

Years ago, during my "marketing and sales period", a nurse approached me during a break at a seminar to ask my advice about a patient and his wound. Instead of describing the patient and his problems, she began by describing the wound as the "size of a Florida orange". My confusion must have been apparent by the bumfuddled look on my face because she added "You know ... a Florida orange ... they're larger than the California ones"! Now I don't know which state produces the larger oranges, but this is one of many issues that crop up (pardon the pun) when nurses and other healthcare professional talk about wounds and their appearance.

Assessment is a critical issue in wound care. Improperly or incompletely assessed wound create all types of problems, including incorrect treatment. Recently, I was changing a vacuum-assisted closure device on a patient who also had a periwound yeast rash that was responding favorably to a topical antifungal powder. A resident looked in on us and wanted to know what I was prescribing for the "acne" around the wound!

So, let's look at the critical components of wound assessment.

Document the anatomic location of the wound. Use landmarks to further define location. Use directions such as superior, posterior, medial, etc to describe areas near landmarks. "Rash noted in right inguinal area extending from midpoint laterally to iliac crest". Use correct terminology: for example, trochanter, gluteal fold, ischium, maleolus, sacrum.

Wounds measurements should not be described in terms of fruit, vegetables or coin of the realm. No citrus fruit (of any kind), peas or quarters! Measurements are taken in millimeters or centimeters. Linear measurements should be taken at the greatest length and width perpendicular to each other (see Figure 1).

Note that greatest length and width are not straight up and down. (© C. Worley, UTMD Anderson Cancer Center)

Describe the condition, color and temperature. Use ecchymosed (bruised), erythematous (red), indurated (firm), edematous (swollen), etc. Define the quality of the wound margins. Brown recluse spider bites initially manifest as a diffuse reddened area without any well demarcated borders. Subsequently they "morph" to the well-defined wounds (Figure 2 and 3). Wound edges are either diffuse, well defined or rolled. Also not if the edges are attached to the wound bed or unattached. Unattached wound edges usually indicate some sort of undermining process.

Initial reaction: Brown Recluse spider bite. (Photo courtesy of American College of Physicians)

Three days later. (Photo courtesy of American College of Physicians)

Pattern or distribution refers to the dispersion of lesions within a certain area. Arrangement refers to the position of nearby lesions. The arrangement of lesions can assist in confirming a diagnosis. Satellite lesions are small peripheral areas around a larger central lesion. Linear lesions are found in a straight line pattern. Candidiasis usually presents with numerous "satellite" lesions (see Figure 4). Insect bites from the sarcoptes mite usually present with a linear pattern (see Figure 5).

Diaper candidiasis (Photo courtesy of Dermatlas)

Scabies (Photo courtesy of Ruth Livingstone, The Little Surgery, Stamford, UK)

Describe the types of tissue found in the wound. Normal granulation tissue has a beefy, red, shiny and textured appearance that bleeds readily. Necrotic tissue is usually yellow-gray and soft is called slough (see Figure 6). Black-gray, hard leathery tissue is called eschar (see Figure 7). Hypergranulation tissue has a sort, flaccid texture very different from normal granulation tissue.

Granulation tissue and Slough (© 2003, L. Woodward, UTMD Anderson)

Eschar (© 2003, L. Woodward, UTMD Anderson)

Wound exudate is the accumulation of fluid and can contain cellular debris, WBCs and bacteria. Drainage can be serous (clear), serosanguinous (blood-tinged) or sanguinous (bloody). Drainage from heavily colonized wound may have a tan or milky appearance. Note the amount, color and consistency of wound drainage.

Odor in wounds is a significant diagnostic tool. Blue-green drainage combined with a musty odor usually indicates presence of Pseudomonas in the wound. Make sure the odor is coming from the wound and not from the dressing. Certain types of dressings (i.e. foams and hydrocolloids) have characteristic odors that are enhanced by the proteins found in wound drainage.

Proper assessment of the wound is a critical issue in wound care, requiring good observational skills and current knowledge. Use of proper terminology is critical to accurate communication between members of the healthcare team. Without correct assessment of the wound and skin, proper diagnosis and treatment cannot occur.