5 Assessing the Wound

Round or Elliptical

Often indicates pressure

Jagged Edges

May suggest shear or friction

Irregular shape

Can point to venous issues

Linear

Typically due to trauma or friction

Partial Thickness Wound

Involves damage to the epidermis and into but NOT through the dermis

Granulation tissue, eschar and slough NOT present

Stage 1

Skin is intact, red, and non-blanchable

Stage 2

Damage is to the epidermis and may include, but does not go through, the dermis

Stage 3

Damage is through the dermis to the subcutaneous level but not through the subcutaneous level

Stage 4

Damage through to deeper structures below the subcutaneous layer

Unstagable

Tissue damage cannot be determined because slough or eschar blocks wound bed

Deep tissue injury

Skin non-blanchable deep red, maroon or purple discoloration

Boggy; common for a thin blister to form over surface of discoloration prior to evolving into an eschar

Wagner scale

Most common classification system used for diabetic foot ulcers

Grade 0 DM Ulcer

Intact skin with or without pre-ulcerative lesions or healed ulcers

Grade 1 DM Ulcer

Superficial ulcer that is a partial or full-thickness ulcer

Grade 2 DM Ulcer

Deep ulcer that extends to ligament, tendon, joint capsule, or deep fascia with no abscess or osteomyelitis

Grade 3 DM Ulcer

Deep ulcer with abscess, osteomyelitis, or joint sepsis

Grade 4 DM Ulcer

Gangrene of a portion of the foot

Grade 5 DM Ulcer

Gangrene of the whole foot

Vascular Wounds

Caused by venous or arterial insufficiency or a mixture of both

Venous Ulcers

Usually found on medial side of the lower leg between the ankle and knee

Shallow and irregular shape that does NOT involve bone or muscle tissues

WET; edema

Arterial Ulcers

Usually found on lateral malleolus, tips of toes, anywhere the is pressure from walking or footwear

Small, usually round, punched-out appearance; well-defined

DRY; yellow, pale, black, grey

Dehiscence

Partial or complete separation of a surgical wound along the incision line, often occurring before the wound has fully closed

Tunneling

Channel or pathway 88that extends in any direction from the wound through subcutaneous tissue

Undermining

Parallel to wound space, creates a shelf life appearance

Destroys tissue beneath intact skin along the wound margin

Serous

Thin, clear, watery plasma

Moderate to heavy amounts can indicate a high bioburden

Sanguineous

Bloody discharge, common in small amounts during inflammatory phase

Serosanguineous

Thin, watery, and pale red to pink

Indicates plasma mixed with red blood cells due to minor capillary damage

Seropurulent

Appearing thin, watery, cloudy and yellow to tan

Often signals an impending infection

Purulent

Thick, opaque drainage

Can be yellow, green, or gray

NEVER normal in a wound

Viscosity

Thickness or stickiness of the exudate

Low viscosity exudate

Thin and watery, potentially resulting from low protein content

Often seen in EARLY stages of wound healing; MAY be normal

High viscosity exudate

Indicates a high amount of protein

Potentially from elevated bacterial levels or inflammatory process