Part of the ICU Emergencies Hub — browse every related guide in one place.
Every wound assessment should address the following characteristics systematically:
| Characteristic | What to Assess | Clinical Significance |
|---|---|---|
| Location | Anatomical site; use body landmarks (sacrum, coccyx, trochanter, heel) | Identifies pressure points, vascular supply considerations |
| Size | Length x width x depth in centimeters; "clock method" for tunneling (12 o'clock = toward head) | Tracks healing progress; growth = deterioration |
| Wound bed | % granulation (red/beefy), % slough (yellow/fibrinous), % eschar (black/tan/hard), % epithelialization (pink/shiny) | Determines debridement need and dressing selection |
| Wound edges | Attached vs. unattached; rolled/undermined edges prevent healing; hyperkeratotic edges = too dry | Undermining means wound is larger than visible surface |
| Exudate | Amount (none/scant/moderate/heavy); type (serous/serosanguineous/sanguineous/purulent); odor | Purulent + malodor = infection; heavy exudate = foam dressing needed |
| Periwound skin | Erythema, maceration (white soggy skin), induration, warmth, edema | Maceration = too wet; induration + warmth = early infection or cellulitis |
| Tunneling/undermining | Tunneling: narrow channel in one direction; undermining: tissue destruction extending under wound edges all around | Both require packing to prevent abscess formation |
| Pain | Pain at wound site, especially with dressing changes; use 0–10 scale | Increased pain can signal infection or ischemia |
The National Pressure Injury Advisory Panel (NPIAP, formerly NPUAP) uses this staging system:
| Stage | Description | Key Feature | Nursing Action |
|---|---|---|---|
| Stage 1 | Non-blanchable erythema of intact skin; skin intact but red that does NOT whiten with finger pressure | Skin INTACT; red that stays red when pressed | Relieve pressure immediately; reposition q2h; barrier cream; do NOT massage reddened area |
| Stage 2 | Partial-thickness loss of dermis; shallow open wound with pink/red wound bed; may be intact or open blister | Skin surface BROKEN; shallow; no slough or eschar | Moist wound healing; hydrocolloid or foam; protect blister if intact |
| Stage 3 | Full-thickness tissue loss; fat may be visible; slough may be present; tunneling/undermining possible; no bone/tendon/muscle visible | Full-thickness; fat visible; NO bone/tendon visible | Wound care with appropriate dressing; notify wound care specialist; nutritional support |
| Stage 4 | Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes tunneling/undermining | Bone, tendon, or muscle EXPOSED | Wound care specialist; surgical consult; aggressive nutritional support; infection monitoring |
| Unstageable | Full-thickness tissue loss; wound base is completely covered by slough and/or eschar so depth cannot be determined; CANNOT stage until debrided | Cannot see wound base due to slough/eschar | Debridement needed before staging possible; heel eschar = keep dry and intact unless infected |
| Deep Tissue Injury (DTI) | Persistent non-blanchable deep red/maroon/purple discoloration on intact OR non-intact skin; may evolve rapidly or resolve; caused by pressure/shear on soft tissue | Purple/maroon color on mostly intact skin; tissue damaged from INSIDE OUT | Off-load immediately; do NOT massage; monitor closely for evolution; may worsen despite intervention |
| Wound Type | Characteristics | Key Nursing Considerations |
|---|---|---|
| Venous leg ulcer | Lower leg/gaiter area; irregular edges; shallow; wet/weeping; brown hemosiderin staining of surrounding skin; minimal pain | Compression therapy (30–40 mmHg) is PRIMARY treatment; elevate extremity; moisture-retentive dressings |
| Arterial ulcer | Toes/foot/bony prominences; round punched-out appearance; deep; minimal exudate; pale/necrotic wound bed; PAINFUL; diminished or absent pulses; pale, shiny skin; ABI <0.8 | NO COMPRESSION (cuts off blood); refer vascular surgery; protect from trauma; elevate HEAD of bed (gravity helps perfusion) |
| Diabetic (neuropathic) ulcer | Plantar surface/pressure points; callus formation; deep; patient often unaware due to neuropathy; warm foot with palpable pulses (unlike arterial); charcot foot possible | Off-loading (total contact cast); blood glucose control; debridement; infection vigilance (can progress to osteomyelitis); daily foot inspections |
| Surgical wound | Clean, linear incision; approximated edges; classified by contamination: clean/clean-contaminated/contaminated/dirty | Monitor for dehiscence (wound opening) and evisceration (organ protrusion); EVISCERATION = cover with moist sterile saline gauze, call surgeon immediately, position supine with knees flexed |
| Phase | Timing | What Happens | Appearance |
|---|---|---|---|
| Hemostasis | Seconds to minutes | Vasoconstriction; platelet plug formation; coagulation cascade | Bleeding controlled; clot forms |
| Inflammation | Days 1–5 | Vasodilation; WBCs migrate (neutrophils first, then macrophages); phagocytosis of bacteria/debris; growth factors released | Classic signs: redness, warmth, swelling, pain; normal for first 3–5 days |
| Proliferation | Days 3–21 | Granulation tissue formation; angiogenesis (new blood vessels); fibroblast activity; wound contraction; re-epithelialization | Red, beefy granulation tissue; wound shrinking; new pink epithelium at edges |
| Remodeling/Maturation | 21 days to 2 years | Collagen remodeling; scar tissue formation; tensile strength increases (never exceeds 80% of original tissue) | Scar formation; may remain pink/raised then fade and flatten |
| Dressing Type | Best For | Key Features | Change Frequency |
|---|---|---|---|
| Hydrocolloid | Stage 1–2; minimal exudate; clean wounds; under compression | Waterproof; promotes autolytic debridement; maintains moist environment; can stay on 3–7 days | q3–7 days or when leaking |
| Foam | Moderate to heavy exudate; Stage 2–3; fragile periwound skin | High absorbency; cushioning; non-adherent; comfortable | q3–5 days depending on exudate |
| Alginate | Heavy exudate; packing wounds with depth; infected wounds (silver alginate) | Derived from seaweed; forms a gel when wet; highly absorbent; requires secondary dressing | Daily to q2–3 days depending on exudate |
| Hydrogel (sheet or amorphous) | Dry/necrotic wounds; painful wounds; partial-thickness burns | Donates moisture to wound; promotes autolytic debridement; cooling/soothing; contraindicated in heavily exudating wounds | q1–3 days |
| Silver-containing | Infected or high infection-risk wounds | Broad-spectrum antimicrobial; do NOT use once infection cleared (toxic to granulation tissue) | Per manufacturer; typically q2–7 days |
| Wet-to-dry (gauze) | Mechanical debridement; RARELY first choice; granulating wounds should use non-adherent dressings | Non-selective debridement; removes slough AND healthy tissue; painful; labor-intensive | q8–12 hrs (3x/day) |
| Negative Pressure Wound Therapy (NPWT/VAC) | Stage 3–4; complex wounds; surgical wounds; dehisced wounds | Subatmospheric pressure promotes granulation; removes exudate; reduces edema; contraindicated in necrotic tissue, untreated infection, exposed vessels/organs | Dressing change q48–72 hrs typically |
Proper wound documentation protects the patient, protects the nurse legally, and communicates to the whole team. Include:
Get the ICU Notebook
Free investing strategies built for nurses. One email per week, no fluff.
Yes, send it freeNo spam. Unsubscribe any time.