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:

1. Assess anatomical location, wound margins, presence of drainage, and healing ridge.

14. For wounds healing by secondary intention:

1. 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.

Equipment for Assessing Wounds

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:

1. Clarify the necessity of reporting any wound drainage observed on sheets or seeping through the dressing.
2. Highlight the significance of reporting any odor detected in the vicinity of the wound.

1. Identify your agency’s approved wound assessment tool and review the assessment frequency. Compare the upcoming wound assessment with the previous one.
2. Evaluate the resident’s comfort level or pain using a scale of 0 to 10, and recognize any signs of anxiety.
3. Provide a clear explanation of the wound assessment procedure to the resident.

1. Assess the wound compared to the previous evaluation to gauge healing progress.
2. If there is no improvement or signs of deterioration, consider consulting a wound care specialist.
3. Lack of healing progress may indicate infection.
4. Notify the healthcare provider and the wound, ostomy, and continence (WOC) nurse or team.

Document the findings of the wound assessment and compare them with previous assessments to track wound healing progress.