not about the wound, but rather about the innate capacity
of the patient for healing, and it is frequently subtle hints
that emerge from the patient assessment that will have
significant influence on how or whether the wound will
heal. Consideration of data obtained from the assessment
will inform patient and wound management strategies
by pinpointing the cause of the wound, and providing
baseline data for comparison over time of the progress of
healing and effectiveness of interventions. However, unless
the information is documented accurately, and in a timely
manner, treatment will potentially fail, exposing health
professionals to litigation and questions over professionalism.
Assessment cannot be viewed as a one-off task carried
out when the wound is first identified, but as an ongoing,
dynamic process as the characteristics change with the
local treatment and, more significantly, with the patient’s
health and medical condition. The changes may indicate
the need for referral for specific problems, such as the
podiatrist specializing in diabetic wounds to remove callus
build-up, or the plastic surgeon to advise on skin grafting
for large areas of tissue loss. Hence the importance of
updating and/or modifying the care plan, so that patient
and wound management reflects these changes, ensures it
is evidence-based and in line with organizational protocols
and formularies, and considers patient preferences.
olistic assessment of the patient with a chronic
wound is an essential prerequisite to the successful
management and outcome of his/her care. It is
Holistic assessment skills
The ability to assess the patient with a wound holistically
requires a knowledge of the physiology of the skin and
the underlying tissue, the ability to identify relevant risk
factors and potential impediments to healing, the ability to
discriminate between significant and non-significant data,
both subjective and objective, and the ability to analyse
and interpret findings from the assessment. Throughout
the assessment, the patient’s perceptions, insight into the
cause of the wound, and their attitude towards it, must be
acknowledged. This will involve ascertaining the physical,
psychological and social factors which may influence
healing. For example, the impact of a chronic, non-healing
pilonidal abscess excision in a young working person can
have devastating effects on his/her self-esteem, financial
status, career prospects, and desire to socialize. It may also
affect concordance to recommended treatment further
extending the time for healing. These possibilities need
to be anticipated by the health professional and strategies
should be put in place to manage them.
The initial part of any assessment should focus on the
individual, e.g. his/her age, level of mobility, nutritional
status, medication, mental state, degree of dependence and
attitude to the wound and healing. A full medical history
should be taken to identify significant medical conditions
that may impact on the development of the wound and
the patient’s capacity for wound healing, as well as the
recording of lifestyle choices, psychological problems and
perceptions of quality of life.
Factors affecting wound healing
The factors influencing healing may be categorized
into systemic and local, but each will impact on the
other. Systemic factors relate to the patient’s health or
disease state, while local factors directly influence the
characteristics of the wound (Guo and DiPietro, 2010).
As the skin ages, collagen content decreases, and so it is
less able to withstand injury, and its capacity for healing is
reduced (Desai, 1997). Therefore, wounds in older patients
may heal more slowly than those in younger patients.
The increasing coexistence of morbidities that occur as a
person ages will also increase the risk of breakdown and
compromise immune, circulatory and respiratory systems,
nutrition, hormonal responses and hydration (Hess, 2011).
A review of the literature of gender differences in skin
suggested that hormonal interactions influence differences
in the propensity for healing between genders, but that
more research is needed to elicit the exact mechanisms
(Kazin, 2007). Body type may also adversely affect wound
Wound care: ensuring a holistic and
Maureen Benbow is Senior Lecturer,University of Chester
Wound assessment has developed into a specialized and complex area
of nursing practice. Care plans and interventions are based on the initial
assessment, which must therefore be accurate and clearly documented to
support correct ongoing wound care and patient management. It is vital that
the underlying and contributing patient factors to both wound development
and healing, delayed healing or non-healing are considered throughout the
process. Evaluation of interventions must be regular and consistent.
w Wound exudate w Assessment w Management w Dressings
Wound Care, September 2011
BJCN_16_9_WCA_woundassessment.indd 616/08/2011 11:40
healing; for example, poor blood supply in adipose tissue
in an obese patient combined with protein malnutrition or
the lack of oxygen and nutritional stores in an emaciated
patient indicate the need for initial and ongoing nutritional
monitoring (Hess, 2011).
Many diseases, for example, cancer, cardiovascular disease
and diabetes, are associated with psychological stress
through deregulation of the immune system (Boyapati and
Wang, 2007). This has a great impact on human health
and social behaviour (Guo and DiPietro, 2010) which, in
turn, significantly impairs wound healing (Godbout and
Glaser, 2006). The patient’s attitude to the wound and its
implications will determine their degree of concordance
with the management plan.
Vascular insufficiency causes ischaemia and oedema
resulting in chronic wounds and compromised healing.
Decreased blood supply is a common cause of arterial,
venous, pressure and diabetic ulcers. For example, venous
insufficiency is defined as disturbance in the forward flow
of blood in the lower extremities that may progress to
increased hydrostatic pressure, venous hypertension and
dermal ulceration (Wound, Ostomy and Continence
Nurses Society, 2009). It is vital to accurately identify
the underlying aetiology of the resulting wound to
enable appropriate treatment. Diabetic ulceration and
non-healing may occur as a result of the complex interplay
of effects of arterial insufficiency, neuropathy and altered
immune response (Guo and DiPietro, 2010). Suppression
of the immune system by disease, medication, or age can
also delay wound healing (Hess, 2011). Many medications
such as steroids, non-steroidal anti-inflammatory drugs
and cytotoxic drugs can inhibit the healing process
by interfering with clot formation, platelet function,
inflammatory responses and cell proliferation (Guo and
Additional factors to be considered include local wound
ischaemia owing to peripheral vascular disease, the systemic
effects of smoking (Siana et al, 1992), or localized oedema
associated with cardiovascular disease (Leaper and Harding,
1998). It is known that chronic alcohol exposure has two
main effects. Firstly, it has been demonstrated to impair
wound healing, and secondly, it increases susceptibility to
infections although the exact mechanisms are unknown
(Szabo and Mandrekar, 2009).
While nutritional depletion and changes in energy,
protein, fat, vitamin and mineral metabolism are known
to be instrumental in adversely affecting wound healing
(Levinson and Demetriou, 1992) and that nutritional
supplementation has a proven positive effect, the exact
mechanisms are again unknown (Arnold and Barbul, 2006).
Therefore, ongoing nutritional assessment is essential to
ensure that the patient is receiving the necessary type and
amount of nutrients for healing.
Ongoing nutritional assessment is necessary because
the visual appearance of the patient or the wound is not
a reliable indicator of whether the patient is receiving
the proper amount of nutrients. Albumin and prealbumin
levels, total lymphocyte count, and transferrin levels
are markers for malnutrition and must be assessed and
monitored regularly, as protein is needed for cell growth.
Concepts such as wound bed preparation (Falanga, 2000)
and frameworks such as TIME (Schultz et al, 2005)
are systematic approaches that can help to formalize
the assessment and may positively contribute to ideal
individualized patient and wound management.
Wound healing can be delayed by factors local to
the wound itself, including desiccation, infection or
bacterial imbalance, maceration, necrosis, pressure, trauma,
and oedema. Wound bed preparation aims to remove
the barriers to healing and initiate the repair process
(Enoch and Harding, 2003). The components of wound
bed preparation are debridement, treatment of infection,
management of exudate levels and restoration of healthy
granulation tissue in the wound bed applied together in a
systematic manner (Enoch and Harding, 2003).
Devitalized tissue may present as necrotic tissue or slough
and usually results from an inadequate local blood supply.
Necrotic tissue or eschar is dark in colour, with dehydrated
dead cells, while slough, which is normally yellow,
fibrinous tissue, consists of fibrin, pus and proteinaceous
material (Enoch and Harding, 2003) and is thought to
be associated with bacterial activity (Thomas, 2000). It
is suggested that the presence of devitalized tissue in a
wound acts as a physical barrier to healing and promotes
bacterial colonization, preventing complete repair of the
wound (Enoch and Harding, 2003), and so debridement,
maintenance debridement throughout management, and
removal or modification of the underlying cause are
essential elements of wound bed preparation.
All open wounds become colonized by bacteria
quickly which will not usually delay or prevent healing.
Infection occurs when pathogenic organisms multiply
and are found in large numbers in a wound (Bale et
al, 2000). Wound infection, caused by micro-organisms
evading the host immunological defences, entering and
multiplying successfully in the tissues, may present as
cellulitis, suppuration, lymphangitis, osteomyelitis, sepsis
or bacteraemia. The patient may be pyrexial, tachycardic,
tachypnoeic and have a raised white cell count (Collins et
al, 2002). The number of macrophages (a white blood cell
responsible for ingesting, removing or destroying foreign
material) decreases reducing elderly peoples’ resistance to
bacterial colonisation and infection.
Local signs to assess include the classic signs of heat,
redness, pain and swelling but these may not be obvious
in the early stages of infection (Bale et al, 2000) so
identification of the more subtle and less obvious signs of
infection as outlined by Cutting et al (2005) is necessary.
The traditional criteria for wound infection suggested
as abscess, cellulitis, discharge (serous with inflammation,
seropurulent, haemopurulent and/or pus) have been
broadened to include delayed healing, discolouration,
Wound Care, September 2011
BJCN_16_9_WCA_woundassessment.indd 816/08/2011 11:40
friable granulation tissue, unexpected pain/tenderness,
pocketing at the wound base, bridging of the epithelium
or soft tissue, abnormal smell and/or wound breakdown
(Cutting et al, 2005). There remains debate about refining
and defining these criteria.
The presence of biofilms may contribute to delayed
healing in chronic wounds, as bacteria proliferate they form
microcolonies that attach to the wound bed and secrete a
biofilm that protects the bacteria from antimicrobial agents
(Davey and O’Toole, 2000).
A moist environment facilitates cell migration, but
imbalance, owing to overhydration can lead to maceration,
and desiccation, or drying out of the wound, which can
prolong the healing process (Bale and Jones, 1997). The
wound may become stuck in the inflammatory phase of
healing (Falanga, 2001). Addressing the necrotic burden
and microbial imbalance effectively, cleaning the wound
and applying appropriate dressings and/or therapies (e.g.
compression therapy for venous leg ulceration) to suit the
level of exudate should help to redress the imbalance.
The normal wound healing process may be impaired in
chronic wounds through changes in the cells required for
healing, and their response to molecular regulation which
is frequently linked to systemic disease processes. The cells
may have become senescent (old, unresponsive and unable
to divide), leading to non-healing or delayed healing (Guo
and LaPietro, 2011). The key to improved healing will
be correction of these underlying physiological problems
and adequate preparation of the wound bed for healing.
Following the principles of TIME should enable barriers
to be removed, encouraging healing and facilitating repair.
The principles of time are (Schultz et al, 2005):
w Tissue non-viable or deficient: does the wound contain
non-viable tissue such as necrotic tissue, slough, non-
viable tendon or bone?
w Infection or inflammation: does the wound have signs
of bacterial contamination, infection or inflammation?
w Moisture imbalance: does the wound have excess exu-
date, or is the wound too dry?
w Edge of the wound non-advancing or undermine: are
the edges of the wound undermind and is the epidermis
failing to migrate across the granulatuon tissue?
Local trauma from inappropriate dressing application
and removal, patient interference with the wound, excessive
exudate, and allowing wounds to cool, will all impact
negatively on healing (McGuiness, Vella and Harrison,
2004). Not all wounds will heal, and so a realistic care plan
would document palliation of symptoms and improving
quality of life, rather than strategies (Benbow, 2007).
Collier (2003) identified a range of components that must
be considered as part of the assessment process, including:
w Identifying the cause and underlying aetiology of the
w Location and characteristics of the wound
w Grading the wound (where applicable)
w Deciding on primary treatment objectives.
From this part of the process, clinical decisions can be
made regarding how the identified treatment objectives
can be achieved (Collier, 2003).
the ‘big picture’
The initial assessment takes in the ‘big picture’ (Davidson,
2002) and provides information about the location,
size and shape of the wound, giving useful clues to its
cause. There must be a systematic approach to wound
assessment, which starts by classifying the wound and
information gathering using various assessment tools and
investigations, identifying treatment objectives, deciding
on the appropriate interventions, and documenting the
findings (Collier, 2003). Identifying the wound by type, e.g.
malignant, acute or chronic, and healing or non-healing,
provides important information for assessment.
When documenting the location, anatomic landmarks
should be used for description, e.g. the right ischial
tuberosity, the lateral border of the left foot. Body
diagrams, carefully used, can be invaluable. The shape of the
wound can also lead to judgements based on knowledge
of the effects of direct, unrelieved pressure over a bony
prominence, for example, a circular lesion on the heel
resulting from the pressure caused by the weight of the
leg on the mattress or stool. The size, shape and depth of
the wound, combined with knowledge of the cause, can
give important clues about the length of time it will take
Wound assessment tools should be used to record details
of assessment, such as (Hollingworth and Collier, 2000):
w Number of wounds
w Clinical appearance
w Description of material in the wound base
w Presence/abscence of exudate
w Serous fluid/pus
w Assessment of pain.
Exudate is the cloudy fluid that seeps out of blood
vessels as a result of inflammation and injury and contains
blood cells and protein, whereas serous fluid is clear and
appears as a result of imbalanced hydrostatic and osmotic
pressures (White, 2006).
There are many ways of classifying wounds, but one
universal system may not be suitable. For example, use of
the European and National Pressure Ulcer Advisory Panel’s
(2009) pressure ulcer grading system would be unsuitable
for grading leg ulcers owing to the different aetiology and
wound development that informed the tool. The right tool
can significantly aid communication, and help to anticipate
wound development, if used appropriately. Wounds may be
simply described as (Baranoski and Ayello, 2008):
w Superficial, affecting the epidermis and the upper der-
w Partial, through the epidermis and dermis
Wound Care, September 2011
BJCN_16_9_WCA_woundassessment.indd 10 16/08/2011 11:40
w Full thickness, penetrating through the epidermis, der-
mis, subcutaneous tissue, muscle and down to bone.
These definitions are dependent on the damage by tissue
layer. Such classifications say nothing about the exudate
level, odour or condition of the surrounding skin which
will all strongly influence the choice of management and
assume knowledge of the anatomy of skin.
The material in the wound can be described simplistically
using the colour classification as an adjunct to the
descriptor (Cuzell, 1988):
w Yellow (sloughy)
w Black (necrotic)
w Green (infected)
w Red (granulating)
w Pink (epithelializing)
However, wounds cannot be accurately staged, classified
or categorized if filled with thick slough or necrotic
tissue (Table 1). Wounds will frequently present with a
mixture of slough, necrosis, granulation tissue, so using
such a classification is not always straightforward. This also
presupposes that health professionals have the necessary
knowledge to accurately distinguish different wounds.
Various wound classification systems are in use that
attempt to aid the assessment process. Formal grading
systems have been developed to describe the degree of tissue
damage associated with diabetes, e.g. the Wagner (1987) and
University of Texas (Lavery et al, 1996) classifications, but
wounds rarely fit into predetermined categories.The aim
is to use multiple assessment tools to provide information
on the different wound parameters to allow accurate
judgements to be made about treatment strategies, improve
documentation and, in turn, improve communication
between the members of the multidisciplinary team.
Following initial assessment, certain investigations will be
required in some cases to further inform diagnosis. These
may include (Doughty et al, 2000; Collier, 2003):
w Doppler ultrasonography: a method for determining
systolic more accurately than with a stethoscope, which
is used when calculating the ankle-brachial pressure
index (ABPI) to exclude peripheral arterial disease
w Venography: injection of a radioopaque dye into the
lower limb veins to detail the venous system compu-
terized tomography and magnetic resonance imaging
(MRI) depending on the findings of the assessment
w Computerized tomography
w Magnetic resonance imaging, depending on the find-
ings of the assessment.
Alternative investigations may include colour Doppler
ultrasound, duplex scanning or photoplethysmography,
which is a non-invasive test. Tissue biopsy is indicated
for identification of infections (microscopy, culture and
sensitivity) or immune complexes, and for chronic wounds
that are not healing at the expected rate. Tissue biopsy
can provide valuable diagnostic histological findings
that may change prognosis and treatment (Alavi et al,
2010). Haemoglobin deficiency decreases blood oxygen-
carrying capacity, and therefore oxygenation estimation
of haemoglobin levels will inform the assessment (Kolb
et al, 1992). There are several non-invasive computer-
based assessment systems available which can be used to
accurately determine wound dimensions (Collier, 2003).
Assessment of the surrounding skin
Assessment of the skin surrounding the wound is an
essential part of the process, as it is likely to be affected
by trauma from repeated dressing changes and the effects
of exudate. Erythema or redness may be present owing
to inflammation associated with colonization, critical
colonization, infection, or a hyperaemic response to
prolonged pressure which has occluded the local blood
supply resulting in inflammatory changes (Collins,
Hampton and White, 2002).
There may be evidence of dermatitis, allergy, blistering or
a build-up of callus around wounds on the feet. Maceration
and/or excoriation may have resulted from incontinence,
inadequate dressing absorbency or inappropriate dressing
choice. Maceration is overhydration or waterlogging of
the skin, and excoriation is skin stripping as a result of
prolonged exposure to toxins on the skin (Collier, 2003).
Induration presents as a change in the texture of skin
where it becomes harder and less supple. Based on the local
wound assessment, decisions will be made regarding the
need for cleansing and the best dressing choice.
Assessment of pain
Seers (1989) stated that there is no predictable relationship
between the severity of an injury and pain which can
arise from any damaged tissue. Collier and Hollinworth
(2000) identified preventing pain and wound trauma as
key considerations for nurses during dressing changes.
For patients with intact sensation, some degree of pain is
associated with having a wound, but there is a tendency for
health professionals to underestimate this, especially as pain
intensifies (Seers, 1987; Grossman et al, 1991; Field, 1996;
McCaffery and Ferrell, 1999). The loss of independence
linked to pain negatively impacts on quality of life.
Hollinworth (2005) suggested that using a wound pain
assessment tool that included both a numerical and verbal
rating scale would improve clinical practice. She also
Wound Care, September 2011
table 1. colours used to describe the clinical
appearance of wounds
Necrotic area of hard, dead tissue
Slough. Dead cells accumulated
Infected. Pus with offensive odour.
Signs of inflammation
Epithelialization. White/pink tissue
Adapted from Cuzzell, 1988
BJCN_16_9_WCA_woundassessment.indd 1216/08/2011 11:40
Wound Care, September 2011
essential that the effectiveness of the chosen interventions
is evaluated regularly. The frequency of formal evaluation
will be decided by the first level nurse based on the
findings from each assessment, but the author recommends
that there must be documented evidence at every dressing
change detailing whether the dressing/therapy is:
w Managing the exudate effectively
w Controlling the odour
w Staying in place
w Acceptable to the patient
w Causing pain or irritation to the surrounding skin
w Achieving the aims of management in the care plan.
The ongoing assessment should note any changes in
(European Wound Management Association, 2005):
w Evidence of fistula/sinus development
w Extension or tunnelling
w The clinical appearance of the wound
w Exudate levels odour
w Signs of inflammation or infection
w The condition of the surrounding skin
If pain is an issue, time of onset, duration, location,
intensity and quality should be explored by discussion and
the use of a validated pain assessment tool. Any local and
systemic barriers, or potential barriers to healing, should
be identified from the assessment and controlled where
possible to facilitate optimal healing. All patients are
individuals and will require different information during
and after the process of assessing and managing the wound,
which should be presented in an accessible form.
Sally, a 62-year-old lady and type 2 diabetic, was suffering
from a sloughy neuroischaemic diabetic foot ulcer. She
was reluctant to follow the instructions of the community
nurse regarding offloading, skin inspection and keeping
dressings in place. She had a busy social life and insisted on
wearing high heels. Treatment options include:
w Health education/promotion, leading to agreement and
acceptance or compromise regarding types of dressings
and strategies for offloading.
Assessment should consider the psychological and social
aspects of having a wound, as involving the patient in their
treatment decisions has a better chance of success.
James, 95, had developed a left ischial tuberosity pressure
ulcer which was granulating. He spent most of the day
sitting in a chair. Treatment options for this patient include:
w Discussing and implementing a repositioning schedule
to divide his time between the chair and bed, as the
appearance of the wound would suggest that it was
owing to direct pressure
w Changing dressings would be easily accomplished while
detailed a number of recommendations for reducing pain
associated with wound management and dressing use that
included warming cleansing solutions, removing dressings
carefully, and, in accordance to manufacturer’s guidelines,
to employ the use of ‘time out’ to allow patients to cope
with the dressing change.
Complete, clear and comprehensive documentation is
essential, both as a record of best practice and a vital
communication tool (Collier, 2003). The language should
be unambiguous and accurately describe the findings.
Documented baseline data will help to monitor and
measure healing progress, or lack of it, over time as it is
used for comparison. Various methods may be used to
measure wounds, such as using a basic ruler. An accurate
measurement of the longest length and widest width
should be recorded. This can be done with the ruler alone,
protecting the wound with sterile plastic, or by tracing the
outline of the wound on to acetate and measuring it.
The wound should be covered with a sheet of clear
plastic, e.g. from the dressing pack or packaging, with the
sterile side to the wound and the acetate or grid on top.
A fine permanent marker will need to be used, and the
tracing annotated or transferred onto paper and annotated.
The soiled plastic sheet is discarded. The tracing must
contain the patient’s hospital number, name, date, location
and orientation of the wound, e.g. top, bottom, and the
measurements in cm. Possible limitations of tracings
include the difficulty associated with a large wound,
maintaining asepsis, lack of measurement of the surface
area, and associated pain. The face of a clock may also be
used to indicate the position of the wound in relation to
the rest of the body (Hess, 2002).
If the wound is erythematous, the red area may also
be indicated with a broken line on the tracing, which
is then stored in the patient’s case notes. An estimation
of the different types of tissue in the wound should be
encouraged and documented, for example, 50% slough,
30% granulation tissue and 20% necrotic tissue. Measuring
depth accurately is almost impossible, and does not have
much value in assessing progress, as consistency between
health professionals in technique is difficult. It is better to
use a tool that describes the extent of affected tissue by
structure, for example, pressure ulcer categorization.
Photographing wounds is a useful adjunct and is easy
to do with modern digital cameras. However, this cannot
be relied on as the sole record for comparison of healing
progress for similar problems with consistency (Benbow,
2007). The purpose of taking photographs must be
specified, and informed consent must be gained by the
health professional. Local protocols must be followed for
storing records and protection of data.
Wound assessment can never be a one-off exercise. When
a treatment plan has been agreed and implemented, it is
BJCN_16_9_WCA_woundassessment.indd 1316/08/2011 11:40
KEY POInts Download full-text
w Holistic assessment is an essential prerequisite to the successful
management of a patient with a wound
wEvaluations of interventions must be regular and consistent
wAll patients are individuals and will need different information, which
should be presented in an accessible form
wA structured approach to assessment is essential for patient outcomes
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he was lying, and the necessary time dedicated to the
correct application of the dressings
w Dressings choice would be guided by the volume of
exudate, wound location and previous experience with
different dressings, which should be documented.
Jane, a 78-year-old-lady had an infected heel pressure ulcer.
Treatment options for Jane include:
w Considering the value of taking a wound swab and
administering systemic antibiotics. Will this alter a treat-
ment plan that includes silver or honey dressings?
w If sloughy, consider desloughing with a hydrogel or
hydrocolloid. If dry, use a hydrofibre or alignate dressing
if wet. If dry, use a hydrofibre, or alignate dressing if wet.
w Alternatively, use DebrisoftTM as a mechanical method
for removing slough
w Relieving pressure from the heel to limit the damage
and promote healing.
Wound assessment is as much about the patient’s
comorbidities, attitudes and capacity for healing as it is
about the state of the wound itself, as shown in the case
examples above. It is a dynamic process that should be
conducted by a suitably educated health professional who
can solve problems using a sound knowledge base, ensuring
that interventions are evidence-based and appropriate.
While the various recognized approaches to assessment are
helpful, their usefulness may be limited by inaccurate or ill-
informed assessment. Evaluation and reassessment must be
ongoing, accurate, and documented to the highest standard
to ensure consistent communication.
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