1. Before proceeding with wound assessment, ensure familiarity with your agency's approved wound assessment tool and review the recommended assessment frequency.
2. Verify any orders from the healthcare provider related to wound assessment.
3. Gather all necessary equipment and supplies.
4. Begin by performing hand hygiene and ensuring the resident's privacy.
5. Introduce yourself to the resident and any present family members.
6. Identify the resident using two identifiers as per agency policy.
7. Review the resident's last wound assessment for comparison.
8. Ask the resident to rate pain on a scale of 0 to 10 and observe signs of anxiety during explanation of the assessment procedure.
9. Position the resident comfortably for optimal visibility of the wound, exposing only the area necessary for assessment.
10. Use clean gloves to remove soiled dressings, noting color, consistency, odor, and saturation of drainage.
11. Discard dressings and gloves properly, perform hand hygiene, and apply new gloves.
12. Inspect the wound and its location, determining wound healing type (primary or secondary intention) using the approved assessment tool.
13. For wounds healing by primary intention:
- Assess anatomical location, wound margins, presence of drainage, and healing ridge.
14. For wounds healing by secondary intention:
- Assess anatomical location, wound dimensions (length, width, depth), undermining or tunneling, tissue loss extent, tissue type, exudate amount, wound edge characteristics, and periwound skin condition.
15. Apply a prescribed dressing and label it with the time, date, and your initials.
16. Reassess resident's pain level and comfort using the pain scale after dressing application.
17. Dispose of biohazard bag, soiled supplies, and gloves as per agency policy, and perform hand hygiene.
18. Assist resident into a comfortable position, ensuring access to personal items and the call light.
19. Ensure resident's safety by adjusting side rails and bed height.
20. Record wound assessment findings, compare with previous assessments, and document resident's response and outcomes.
1. Before proceeding with wound assessment, ensure familiarity with your agency's approved wound assessment tool and review the recommended assessment frequency.
2. Verify any orders from the healthcare provider related to wound assessment.
3. Gather all necessary equipment and supplies.
4. Begin by performing hand hygiene and ensuring the resident's privacy.
5. Introduce yourself to the resident and any present family members.
6. Identify the resident using two identifiers as per agency policy.
7. Review the resident's last wound assessment for comparison.
8. Ask the resident to rate pain on a scale of 0 to 10 and observe signs of anxiety during explanation of the assessment procedure.
9. Position the resident comfortably for optimal visibility of the wound, exposing only the area necessary for assessment.
10. Use clean gloves to remove soiled dressings, noting color, consistency, odor, and saturation of drainage.
11. Discard dressings and gloves properly, perform hand hygiene, and apply new gloves.
12. Inspect the wound and its location, determining wound healing type (primary or secondary intention) using the approved assessment tool.
13. For wounds healing by primary intention:
- Assess anatomical location, wound margins, presence of drainage, and healing ridge.
14. For wounds healing by secondary intention:
- Assess anatomical location, wound dimensions (length, width, depth), undermining or tunneling, tissue loss extent, tissue type, exudate amount, wound edge characteristics, and periwound skin condition.
15. Apply a prescribed dressing and label it with the time, date, and your initials.
16. Reassess resident's pain level and comfort using the pain scale after dressing application.
17. Dispose of biohazard bag, soiled supplies, and gloves as per agency policy, and perform hand hygiene.
18. Assist resident into a comfortable position, ensuring access to personal items and the call light.
19. Ensure resident's safety by adjusting side rails and bed height.
20. Record wound assessment findings, compare with previous assessments, and document resident's response and outcomes.
1. Utilize gloves due to the potential exposure to infectious microorganisms.
2. Adhere to sterile technique principles when evaluating a surgical wound.
3. Apply the principles of clean technique when assessing a nonsurgical wound.
4. Refrain from removing the initial surgical dressing for direct wound inspection until authorized by the healthcare provider.
5. Consider the resident’s age, nutritional status, weight, risk factors for impaired oxygenation (such as smoking), hemoglobin/hematocrit values, and chronic diseases or exposures, as they can impact wound healing.
1. Utilize gloves due to the potential exposure to infectious microorganisms.
2. Adhere to sterile technique principles when evaluating a surgical wound.
3. Apply the principles of clean technique when assessing a nonsurgical wound.
4. Refrain from removing the initial surgical dressing for direct wound inspection until authorized by the healthcare provider.
5. Consider the resident’s age, nutritional status, weight, risk factors for impaired oxygenation (such as smoking), hemoglobin/hematocrit values, and chronic diseases or exposures, as they can impact wound healing.
Equipment for Assessing Wounds
Protective equipment:
clean gloves
sterile gloves (if needed)
gown, and goggles if splash/spray risk exists
Measuring guide for wound assessment
Cotton-tipped applicator
Dressing supplies
Disposable biohazard bag
Equipment for Assessing Wounds
Protective equipment:
clean gloves
sterile gloves (if needed)
gown, and goggles if splash/spray risk exists
Measuring guide for wound assessment
Cotton-tipped applicator
Dressing supplies
Disposable biohazard bag
The responsibility of wound assessment cannot be delegated to nursing assistive personnel (NAP). It is your duty as the nurse to conduct and record wound characteristics. Prior to delegating any associated tasks, ensure NAP is aware of the following:
The responsibility of wound assessment cannot be delegated to nursing assistive personnel (NAP). It is your duty as the nurse to conduct and record wound characteristics. Prior to delegating any associated tasks, ensure NAP is aware of the following:
Document the findings of the wound assessment and compare them with previous assessments to track wound healing progress.
Sample Documentation for Assessing Wounds
10:00 Abdominal dressing dry and intact. The skin around the dressing is pink with no swelling, bruising, discoloration, or excessive warmth. Resident denies pain on palpation and appears comfortable during the assessment. —T. Wulandari, RN 12/17/23
16:30 Removed initial surgical dressing per order. 3-inch wound is red. Suture line is approximated. Steri-Strips intact. Small amount of serous drainage, no foul odor. Sterile dressing applied. —J. Doe, RN 12/17/23
Document the findings of the wound assessment and compare them with previous assessments to track wound healing progress.
Sample Documentation for Assessing Wounds
10:00 Abdominal dressing dry and intact. The skin around the dressing is pink with no swelling, bruising, discoloration, or excessive warmth. Resident denies pain on palpation and appears comfortable during the assessment. —T. Wulandari, RN 12/17/23
16:30 Removed initial surgical dressing per order. 3-inch wound is red. Suture line is approximated. Steri-Strips intact. Small amount of serous drainage, no foul odor. Sterile dressing applied. —J. Doe, RN 12/17/23