LOCATION SIZE TUNNELING AND UNDERMINING BED EDGES DRAINAGE ODOR WOUND ASSESSMENT LOCATION SIZE TUNNELING AND UNDERMINING BED EDGES DRAINAGE ODOR

Wound LOCATION Laterality Specific anatomical location Body surface (anterior, posterior, etc.) Ex. (+) Stage III pressure ulcer on the sacral area (+) Stage II ulcer on the anterior aspect of ® FA

Wound SIZE (LENGTH & WIDTH) Length: 45cm Width: 15 cm Depth: 10 cm * Width must be perpendicular Length

Wound SIZE (DEPTH) Deepest portion of the wound

Wound SIZE Length x Width = wound surface area (cm2) Depth Techniques: Direct measurement Wound Tracing (contact and permanent layer) a. tracing b. Pre measured grid (cm2)

Wound SIZE DOCUMENTATION: Wound surface area:45 (cm2) Wound depth: 12 cm Or Wound size: 14cm x 7 cm

TUNNELING Distance from the tip of the probe up to wound edge; locate using clock terms

UNDERMINING Distance from the tip of the probe up to wound edge; locate using clock terms

Wound BED Take note of granulation and necrotic tissues amount (%) Sample Documentation: Wound Bed: 50% granulation tissues, 25% slough, 25% eschar APPEARANCE GRANULATION NECROTIC Healthy: beefy red Infected or poor circulation: pale color Slough: Tan or yellow Eschar: black

Wound EDGES Distinctness: define, indistinct borders Thickness: thickened, rolled Attachment to base: attached or unattached

Wound DRAINAGE type, color, amount Type color Consistency Interpretation Serous Clear to pale yellow Watery Normal sanguinous Red,dark brown, Slightly thickened Serosanginous Pink to light red, watery purulent Yellow, green Viscous, creamy Infected *Pseudomonas Blue-green infected

Wound ODOR (+) or (-)

SAMPLE DOCUMENTATION * with attachment of the permanent layer (tracing) Pt’s name: G.G. Date: September 9, 2012 Wound location: anterior aspect of (L) lateral malleolus Wound size: 3.4 x 4.4 cm, depth: 5 cm Wound bed: 25% granulation tissue, 50% yellow adherent slough, 25% adherent black eschar Tunneling: 6cm at 3 o’clock Undermining: 4cm at 5 o’clock to 10 o’clock, Wound edges: distinct, unattached and rolled Wound drainage: copious, purulent Wound odor: (+)