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

2. 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

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

4. Wound SIZE (DEPTH)
Deepest portion of the wound

5. 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)

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

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

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

9. 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

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

11. 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

12. Wound ODOR
(+) or (-)

13. 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: (+)