Sherpath Ch.

48 Skin Integrity and Wound Care

Blue Print for Exams

Chapter 26 - Documentation and Informatics
1. “if you did not write it, you did not do it”
2. Proper documentation, Telephone orders, verbal orders, Informed Consent, purpose of medical records,
discharge summary
Principles of informatics

Chapter 48- Skin Integrity and Wound Care

1. Wound closures-primary, secondary, tertiary intention;
2. Dehiscence vs. Evisceration, proper nursing care for each
Principles of wound care, proper wound care
3. Stages of pressure ulcers, levels of tissue involvement, Braden scale
Infection vs Inflammation
4. Nursing interventions for all the above, including the primary, secondary and tertiary preventions
5. Principals of delegation
6. Patient teaching

Chapter 26 Key Points

 The medical record is a document with comprehensive information about a patient’s health care encounter, as
well as demographic, administrative, and clinical data.
o Serves:
 as a major communication tool between staff members
 a single data access point for everyone involved in the patient’s care.

electronic medical record (EMR) electronic health record (EHR)

 a record of one care episode • a longitudinal record of health care that
e.g. VS includes:
o an inpatient stay o the inpatient and outpatient health care
o an outpatient appointment episodes from one or more care settings.

 Core components of EHRs

1. health information
2. diagnostic results.
MAY ALSO INCLUDE
3. provider order entry system (CPOE – Computerized Provider Order Entry)
4. decision support (DSS -- Computerized Decision Support Systems)

 Registered nurses are responsible for reviewing documentation by UAP for all patients under their care.
 Use of an electronic health record (EHR) system can yield positive results in efficiency and patient care safety,
but EHR use is not without challenges, such as staff adjustments to the new technology and workflow and the
need for back-up plans in case of EHR system failure.
 EHR security is controlled through assignment of individual passwords and verification codes that identify users
who have the right to enter the record.
 EHR security depends on adherence to safe practices by staff when using the EHR.
 Standards for documentation are established by each health care organization’s policies and procedures.
 General principles of medical record documentation from the Centers for Medicare and Medicaid Services
(2010) include:
 Completeness and legibility of all documentation
 Inclusion of the reasons for each patient encounter, including assessments and diagnoses
 Documentation of the plan of care, the patient’s progress, and any changes in diagnosis and treatment

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 Expected nursing documentation includes the nursing assessment, the care plan, interventions, the patient’s
outcomes or response to care, and assessment of the patient’s ability to manage after discharge.
 Nursing documentation must be factual and nonjudgmental, with proper spelling and grammar, and should
reflect thoughtful professional nursing practice.
 Standardized nursing language should be used whenever possible in documentation.
 Nurses must be aware of the dangers of using abbreviations that may be misunderstood and compromise
patient safety, and should use only accepted abbreviations.
 Medical records are legal documents.
 Specific legal considerations related to medical records include handling of errors and changes, timeliness of
documentation, and confidentiality and security of information.
 Within a medical record, nursing documentation may be done in a narrative format or in a problem-oriented
format.
 PIE, APIE, SOAP, and DAR notes are all recognized as common variations of formatted problem-oriented nursing
documentation.
 Flow sheets and checklists are used to document routine care and observations that are recorded on a regular
basis, such as vital signs and intake and output measurements.
 Charting by exception is documentation that records only abnormal or significant data.
 A medication administration record (MAR) is a list of ordered medications, including the specific dosages and
administration schedule, on which the nurse documents medications given or not given.
 Many facilities using electronic medication administration records (eMARs) use bar-coded medication
administration.
 An RN who takes a verbal or telephone order must repeat the order verbatim to the provider to confirm
accuracy and then enter the order into the paper or electronic system, documenting it as a verbal or phone
order and including the date, time, provider’s name, and RN’s signature.
 Admission and discharge summaries are important parts of the medical record because they provide health care
professionals concise and pertinent information about a patient’s hospital visit.
 The term kardex continues to be used generically for certain patient information held at a nursing unit station.

Chapter 48
Overview of Skin
Skin Basics (body’s largest organ - 6 pounds)
1. Regulation of Heat - Steadies body temperature through:
o the ability to dilate and constrict blood vessels
o to produce perspiration in response to changes in internal and external temperature
2. Sensation - Provides tactile feedback:
o to aid in identification of objects in the environment
o to alert us to danger by transmitting the sensations of:
 pressur  pain  temperature extremes
e
3. Production of - Produces vitamin D in the presence of sunlight (duhr?)
Vitamin D
4. Release of Toxins - Assists with:
o elimination of toxins and wastes from the body
o maintenance of fluid and electrolyte balance
5. Protection - Forms an effective barrier against environmental hazards such as:
 ultraviolet light  chemicals  microbes  pathogens

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1. Epidermis 5 LAYERS Structure:

 Outermost layer Outer: - composed of flattened dead cells.
 Thinnest layer - stratum corneum Function:
 No blood supply a. helps provide environmental protection
 Regenerates every b. regulates fluids and electrolytes.
4-6 wks Middle: Structure:
- stratum lucidum - transition between the inner basal and outer layers.
- stratum Function:
granulosum - help reduce friction and shear.
- stratum spinosum
Basal: Structure:
- stratum - only consists of a single layer of cells BUT is very active.
germinativum Function:
1. produces new cells that push through to the stratum corneum
a. where they flatten, die, and are sloughed off.
2. the site of the synthesis of keratin
a. which gives the skin strength and flexibility
b. allows it to repair itself.
3. It contains melanin
a. provides skin coloring
b. protects it from ultraviolet light.
4. It includes Langerhans cells, involved in:
a. the digestion of bacteria
b. the immune system response to foreign materials.
4. Dermis Structure:
 Layer of cells bet. - composed of connective tissue that varies in thickness depending on its specific location.
epidermis and SQ  example, skin on the soles of the feet is thicker than skin on the hands.
- Projections known as rete ridges, or papillary dermis
 anchor the dermis and epidermis together,
 preventing them from sliding back and forth.

Embedded in the dermis are:

 Sebaceous glands  Hair and nail follicles  Lymphatics
 Sweat glands  Nerves !!!! (PAIN) 
Function:
1. Dermal connective tissue contains elastin and collagen fibers
 give skin its characteristic strength and elasticity.
2. abundant dermal vascular system
 provides skin with essential blood and oxygen supplies
5. Subcutaneous Structure:
 Innermost layer - a layer of adipose (fat tissue)
- layer varies by:
 size and location on the body
 person’s weight, sex, and age.
- attaches the dermis to the underlying tissues and bones.
Function:
1. Delivers blood to the dermis.
2. Provides insulation to protect against both heat and cold.
3. Provides cushioning for bony prominences and protection of internal organs.
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Alterations in Skin Integrity

Factors Affecting Skin Alteration

1. Comorbidities
Vascular disease: Vascular disease impairs the skin’s ability to obtain necessary oxygen and nutrients.

Diabetes mellitus:
Diabetes mellitus adversely affects the skin’s microvasculature and its normal acidic pH.
2. Nutrition
Nutritional deficits: Lack of nutrients results in inadequate proteins, cholesterol, fatty acids, vitamins, and minerals.
3. Medications
Medications: Drugs such as steroids, nonsteroidal anti-inflammatory drugs, and anticoagulants may suppress cellular
wound responses and may increase the risk of infection.
4. Moisture
Excessive moisture: Too much moisture can complicate the healing process and allow bacteria to enter the wound,
thereby increasing the risk for infection.
5. External Forces
Pressure, shear, or friction, or a combination of these: External forces against the skin can result in pressure ulcers or
can impair their healing.

Ultraviolet light exposure: Over the longer term, ultraviolet light radiation induces degenerative changes in skin cells.
6. Aging
Aging: The appearance and function of skin is dramatically affected by aging. Changes associated with aging are:

Thinning of the dermis, epidermis, and subcutaneous layers resulting in reduced elastin, collagen fibers, sweat glands,
and sebaceous glands. These changes lead to wrinkled, sagging, dry, thin-appearing skin seen in older adults.
Reduced insulation and cushioning, which increases the risk for skin trauma and temperature extremes.
Decreased melanocytes resulting in loss of hair color and increased risk for skin cancer.
Decreased Langerhans’ cells resulting in decreased resistance to infection.
Flattening of rete ridges, the interconnections between the epidermis and dermis, resulting in increased risk for
mechanical trauma, shearing forces, and skin tearing.

Wounds can be classified in a variety of ways including:

Cause
Open or closed
Depth
Acute or chronic
Presence of infection or contamination

Classification by Skin Integrity

Open
An actual break in the skin’s surface, such as an abrasion, a puncture or a surgical incision.
Some chronic wounds, such as pressure sores or vascular disease sores, are also classified as open wounds.

Closed
The skin is intact, e.g., a bruise.
Closed wounds do not necessarily indicate a more benign condition.
Some injuries first occur below the level of the skin, such as pressure-related injuries or fractured bones; thus, the
integrity of the skin is not a good indicator of the severity of the underlying tissue damage.

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Classification by wound depth

Superficial or partial thickness

Superficial wounds affect only the epidermis.
Partial-thickness wounds affect the epidermis and the dermis but do not extend through the dermis to the subcutaneous
layer.
These wounds tend to heal quickly, without scarring, unless outside factors such as infection delay the normal healing
process.

Deep or Full-Thickness
Deep wounds extend through the dermis into the subcutaneous layer.
Wounds can extend beyond the subcutaneous layer into the muscle, bone, or other underlying structures.
Full-thickness wounds tend to heal slowly and leave scarring.
Full-thickness wounds are more likely to become chronic in nature.

Classification by Contamination Level

Wounds can also be classified on the basis of contamination. These wounds are known as clean, clean contaminated,
contaminated, infected, or colonized.
Classification Characteristics
Clean  No infection and minimal risk for infection, e.g., wound from a closed-surgical incision made in
the controlled, sterile environment of the operating room that does not involve bacteria-
containing organ systems.
 Wound was not contaminated during trauma or from the incident in which the wound
occurred, e.g., laceration received during an automobile crash.
Clean  Similar to a clean wound, but with greater risk of infection.
Contaminated  Surgical involvement of organ system, e.g., bowel surgery with some increased risk for
infection, but not as significant as contaminated.
Contaminated  High risk for infection due to a break in sterile technique during surgery, or from the
perforation of a hollow organ (bowel, etc.) before surgery allowing for spillage of bacteria-
laden material into the surgical area.
 Wound was contaminated during certain types of trauma or accidents with a high risk for
infection, such as penetrating trauma or a fall.
Infected  Presence of a bacterial count of at least 105 per gram of tissue.
 Presence of clinical signs: Redness (erythema), warmth, and increased drainage that may or
may not be purulent (contain pus).
Colonized  Contains one or more organisms present on the surface of the wound in a swab culture, but no
overt sign of infection below the surface.
 Common in chronic wounds and may contribute to delayed wound healing.

Classification by Healing Process

Wounds may be classified by their progression through the wound healing process.
Classification Characteristics
Primary  Quick, uncomplicated healing of an acute wound with minimal scar tissue.
Intention  Examples: Surgical incisions or traumatic wounds in which the edges of the wound can be
brought together (approximated).

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Classification Characteristics
Secondary  Healing in which new tissue fills in from the bottom and sides of the wound until the wound
Intention bed is filled.
 Examples: Chronic wounds or wounds associated with disease processes such as diabetes or
vascular disease, or with other factors that have inhibited proper wound healing.
Tertiary  Healing in which the wound is initially left open for a while after injury and a delay occurs
Intention between injury and closure.
 Examples: Contaminated surgical wounds left open to allow observation and better drainage
(common in GI tract); closed later when infection risk is reduced.

Wound Classification: Burns

Burns are tissue injuries caused to the skin by heat, electricity, chemicals, radiation, extreme cold
(hypothermia/frostbite), or friction. Wounds from burns are classified according to the depth of the lesion, e.g.
superficial or extending into the subcutaneous layer, muscle, and bone. When burns occur over a large percentage of
the body, the patient is at risk for serious complications such as infection and fluid and electrolyte imbalance.
Classification Characteristics
Superficial (First Degree)  Affect only the epidermal layer of the skin but may extend somewhat
deeper
 Result in pain and redness
Superficial and Deep Partial-Thickness  Superficial: Affect epidermal layer and upper third of dermis
(Second-Degree)  Deep partial-thickness: Affect deep layers of the dermis and destroy
structures within the dermis
 Result in extreme pain and blistering
Full-Thickness and Deep Full-Thickness  Damage the subcutaneous tissue, muscle, and bone
 Result in white or brown areas, charring, and loss of sensation

Staging of Pressure Ulcers

Pressure ulcers are also known as decubitus ulcers and bedsores; however, the term pressure ulcer more clearly reflects
the underlying cause of the wound. A pressure ulcer is injury to skin caused by pressure from bony prominences and/or
shearing. Pressure ulcers are classified by type of visible tissue. This is also called staging.

Stage I

 Intact, non-blistered skin

 Non-blanchable erythema or persistent redness in the area of pressure (abnormal reactive hyperemia)
 Painful area that differs in firmness and temperature from surrounding tissues

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Stage II

Partial-thickness wound involving the epidermis and dermis

Shallow and superficial with a pink wound bed
Also includes intact or ruptured blisters from pressure that have not yet cratered

Stage III

 Full-thickness wounds extending into the subcutaneous tissue, but not into fascia, muscle or bone
 May include undermining (tissue loss around edges and under intact skin, forming a lip around the wound)
 May include tunneling (narrow passage-way extending out from the wound)

Stage IV

 Full-thickness wound that is deeper than a stage III wound

 Involves exposure of muscle, bone, or connective tissue (tendons, cartilage)
 Infection of the bone, if exposed, is highly likely

Unstageable

 Full-thickness wound with necrotic tissue (eschar)

 Assessment of wound depth or involvement of underlying tissues is not possible

Suspected Deep Tissue Injury

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 Classification added in 2007

 Observed as an area of intact skin that is purple or maroon or a blood-filled blister
 Similar to stage I ulcers, but difficult to detect in darker-skinned patients
 Depth of tissue damage is not readily apparent on initial inspection; however, these injuries can progress
rapidly, exposing deeper layers of tissue, even if treated quickly and appropriately

Phases of wound healing

The three phases of wound healing are:
1. Inflammatory phase, which includes homeostasis
2. Proliferative phase
3. Maturation phase (remodeling)

Inflammatory
 Begins with the body’s initial recognition of and response to a wound, bleeding.
 Bleeding triggers coagulation cascade, which involves the release of growth factors to form a clot and stop
bleeding.
 Growth factors, along with cytokines also released during this phase, initiate wound healing.
 Blood vessels dilate, leaking fluid into the area of injury (wound) and resulting in classic signs of inflammation:
pain, redness, warmth, swelling, and limited function in the area of injury.
 Macrophages and neutrophils move into the area of injury and begin the process of removing bacteria and
debris, which cleans the wound bed for the repair process.
 Lasts approximately 3 days.

Proliferative
 Healing and repair are primary processes that occur.
 Wound bed fills with new tissue (granulation tissue), resurfacing wound with skin.
o Acute wounds: heal in a rapid, uncomplicated manner.
o Approximated wounds: surgical incisions/traumatic wounds; wound edges can be brought together
easily and heal in an uncomplicated manner.
o Chronic wounds: fail to heal in a timely manner, may be left open for a period of time, often heal by
secondary intention.
 New blood vessels, collagen synthesis, wound contraction, and epithelialization develop.
 New tissue bleeds easily and has granular, bumpy texture.
 Lasts several weeks; can be shorter when wounds are surgically closed and heal by primary intention.

Maturation
 Last phase of wound healing, also known as remodeling.
 Collagen continues to be deposited.
 Scar is formed and strengthened, but scar tissue only reaches 80% of tissue's original tensile strength.
 Lasts up to a year.

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Factors that affect wound healing

Oxygenation

Diseases such as heart disease, peripheral vascular disease, and pulmonary disease affect the body’s ability to perfuse
tissues with adequate amounts of oxygen (hypoxia) and can adversely affect wound healing.
Chronic tissue hypoxia is associated with:
 Reduced collagen formation
 Decreased action and proliferation of fibroblasts
 Reduced leukocytes
 Impaired cell migration
Smoking, while not a disease, is directly associated with pulmonary disease.
 Smoking impairs hemoglobin’s ability to carry oxygen.
 Nicotine causes vasoconstriction and increased coagulability of blood, reducing the body's ability to circulate
oxygen.

Diseases

Diabetes mellitus causes changes in microvascular and macrovascular systems, leading to:
 Thickening of vessel walls and occlusion of blood flow that decreases the supply of nutrients and oxygen to
tissues
 Decreased wound healing exhibited by:
o Reduction in collagen synthesis
o Decrease in strength of collagen
o Impaired functioning of leukocytes
o Reduction in number and action of macrophages

Nutritional Deficits

 Nutritional deficits can adversely affect wound healing. The body requires additional energy to recover and heal
from any injury because overall caloric needs increase.
 Protein needs increase disproportionally to caloric needs because protein is needed by fibroblasts for collagen
synthesis.
 Deficiencies in vitamins C and A, and trace minerals zinc and copper negatively impact skin and wound healing.

Age

The aging process affects all phases of wound healing, although older persons do heal from wounds. As persons age and
are affected by comorbidities and possible effects of medication use, healing occurs at a slower rate because:
 The inflammatory response is decreased or delayed.
 Macrophage and fibroblast action is reduced.
 Collagen synthesis is reduced resulting in slowed wound epithelialization.

Infections

 Can cause delayed wound healing and also be a complication of impaired wound healing.
 Can lead to development of chronic wounds.
 When left open or contaminated, a wound is at increased risk for microorganism invasion.
 Infection can result in:

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o Prolonged inflammatory phase

o Delayed collagen synthesis
o Inadequate or no epithelialization that can lead to additional tissue destruction
o Failure of the wound to progress through normal phases of healing
o Development of a chronic wound
 Wounds showing no progress toward healing despite appropriate treatment must be assessed for an underlying
infection and treated aggressively for infection, if present.

Factors contributing to pressure ulcers

Intensity
 Unrelieved pressure exceeding the normal 12 to 32 mm Hg due to immobility or inability to sense pressure-
related pain leads to tissue ischemia.
 Tissue ischemia leads to actual pressure ulcers.
 Subcutaneous tissue and muscle tissue are more susceptible to pressure than other tissues.

Duration
 Low levels of pressure over long periods of time can damage the skin and underlying tissue as much as high
levels of pressure over a short period of time.
o Pressure has a cumulative effect on tissues. Tissues exposed to pressure, even when pressure is
removed, may experience considerable damage when re-exposed to the same degree or a lesser degree
of pressure later.

Friction/Shear
 Friction involves the rubbing together of two surfaces, e.g. the skin and bed. While friction damages the
epidermal layer, greater damage occurs from shear.
 Shear is the opposing stress of the skin and the surface of the bed as the patient’s weight pulls the person
downward. This pull results in hyperangulation and stretching of the blood vessels, affecting their ability to
transport blood.

Sensory loss, Immobility

 Patients with neurologic conditions such as spinal cord injury, those with chronic conditions that lead to
neuropathies, as in diabetes, patients with dementia or brain injury, and those who are in traction or restraints
or who are unable to reposition themselves independently are at risk because they are:
o Unable to feel pain (the warning sign of tissue ischemia).
o Unable to respond by moving and/or changing positions independently.

Moisture
 Incontinence contributes to the development of pressure ulcers due to the effects of maceration, a condition in
which excessive moisture causes softening of the skin, leaving it vulnerable to breakdown.
 More recent studies show that while the skin may become macerated and the enzymes found in stool can lead
to perineal inflammation and dermatitis, the damage from moisture is confined to the more superficial layers
Kottner, Balzer, Dassen, and Heinze, 2009; Pieper, Langemo, and Cuddigan, 2009).

Malnutrition
 Compromised nutrition inhibits the ability of tissues to withstand the forces of pressure and shear and to
combat infectious agents when patients have:
o Unintentional weight loss of 5% or more
o Low body mass index (BMI)
o Deficiencies in vitamins A, C, and E and the minerals zinc and copper

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o Protein-calorie malnutrition

Complications

Dehiscence, Evisceration

 When healing tissues of surgical incision are under physical stress, they are at risk for two primary complications
of wound healing:
o Dehiscence: Partial or complete separation of tissue layers
o Evisceration: Total separation of tissue layers, allowing protrusion of visceral organs through incision
 Usually occur 5 to 9 days after surgery and are related to a delay in collagen synthesis.
 If a wound is healing properly, a 1-cm-wide ridge, or area of induration, can be palpated next to incision line. A
ridge is indicative of new collagen being laid down in the wound. If a “healing ridge” is not felt, the wound is at
increased risk for dehiscence and evisceration.
 Symptoms include a “popping” sensation accompanied by an increase in drainage from wound. Sutures and
staples may be applied to keep wound closed.

Fistula

 Abnormal connections between two internal organs or between a protruding internal organ and (through the
skin) the outside of body.
 Identified by names of organs involved:
o Enterovaginal: opening between the intestines (entero) and the vagina, allowing intestinal content to
drain into the vagina.
o Enterocutaneous: opening between the intestines (entero) and the skin (cutaneous).
 Usually result from:
o Specific disease processes
o Treatment modalities
o Factors of poor wound healing
 Predispose the affected person to fluid and electrolyte loss and imbalance, nutritional deficits, and alterations in
skin integrity, particularly if the fistula is draining material that is naturally destructive to the skin’s surface, e.g.,
exposure to digestive enzymes normally found in fluids from the small intestine can cause extensive damage to
skin in a short time.

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Key Points

 Knowledge of various wound classifications facilitates communication with patients and health care
professionals.
 Classification by skin integrity includes open wounds, in which the skin’s surface is broken, and closed wounds,
in which the skin's surface remains intact.
 Wounds classified by depth include superficial, partial-thickness, and full-thickness (deep) wounds, based on the
depth of skin layers involved.
 Wounds classified by level of contamination include clean, clean contaminated, contaminated, infected, and
colonized, based on degree of wound contamination.
 Wounds classified according to the healing process are known as primary, secondary, or tertiary intention.
 Burns are classified according to depth of the burn, e.g., superficial (first degree), partial-thickness (second
degree), or full-thickness (third degree).
 Pressure ulcers are classified based on type or stage of ulcer, from stage I to unstageable.
 The phases of wound healing include the inflammatory phase (blood clotting and the natural process of cleaning
the wound), the proliferative phase (repair, filling in the wound bed with new tissue, and resurfacing the wound
with skin), and the maturation phase (skin remodeling).
 Factors that affect wound healing are similar to those that affect the skin’s integrity.
 Factors that can affect and ultimately slow or delay wound healing include disease, smoking, age, nutrition, and
infection.
 Complications of wound healing include dehiscence, evisceration, and fistulas.
 A pressure ulcer is a wound to the skin and/or underlying tissue, usually over a bony prominence, and is the
result of pressure, or pressure in combination with shear.
 Nursing plays a critical role in the identification of patients at risk for pressure ulcers, and the prevention and
resolution of the pressure ulcers.

Assessment related to Skin Integrity

Focused Assessment

 Temperature
 Overall color
 Local variations in color
 Presence of excessive moisture or dryness
 Odor
 Texture
 Turgor
 Integrity
 Presence of wounds
 Presence of risk factors associated with skin breakdown or impaired healing

Focused Questions

 How do you describe the overall condition of your skin?

 Have you ever had any skin problems? If so, what, and when?
 Describe your skin care regimen.
 Describe your diet. Have you experienced any recent unintended weight loss?

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 Are you ever incontinent of urine or stool?

 Have you been told that you have diabetes or problems with your circulation?
 Do you smoke?
 Have you noticed any numbness or tingling in your feet?
 Has it seemed to take a long time for a wound to heal in the past?

Assessing wounds

When a wound is present, an accurate and detailed assessment of the wound is necessary, including:
 Close inspection of the wound to determine possible etiology of the wound unless known (e.g., surgical incision)
 Thorough patient history (e.g., incident that produced the wound)
 Head-to-toe physical examination (e.g., for the presence of other wounds/lesions)
This assessment aids in determining the most appropriate treatment for the wound and serves as a baseline for
evaluation of treatment and wound healing. Additional testing, such as vascular studies to assess arterial and venous
status, laboratory studies to assess for chronic diseases, such as diabetes or malnutrition, or wound biopsy to rule out
infection or malignancy, may also be required.

Wound Assessment Data

Let’s review important information that a nurse would collect during wound assessment.

Focused Wound Assessment

1. Location Describe in clear, anatomic language (e.g., left outer malleolus).
2. Size  Estimate the size of the wound or measure with a disposable tape or ruler.
 Wound size is important when assessing progression of wound healing.
3. Presence of  Determine presence and location of undermining by using a cotton-tipped
undermining or applicator and moving around under the edges of wound.
tunneling  Tunnels into good tissue increase size of wound and must also be treated to
prevent dead space. Dead space predisposes to abscesses, infection.
4. Drainage  Describe presence or absence.
 Describe color.
o Serous: clear, watery fluid from plasma
o Serosanguineous: pink to pale red
o Sanguineous: may be bright red, indicates bleeding
o Purulent: greenish, yellow, or beige; indicates infection
 Estimate or measure amount (if possible).
 Describe consistency.
 Describe odor.
5. Wound edges and  Describe any regeneration of epithelial tissue.
surrounding tissues  Note and describe any maceration; indicates lack of healing.
 Note and describe presence of infection.
 Inspect and describe any new wounds.
6. Wound bed  Describe type of tissue in the wound bed.
 Describe color.
 Examine for pale, dry appearance of presence of foreign bodies, which indicate
disease, comorbidity or trauma, all of which can delay healing.
7. Patient response Describe patient’s pain in response to wound itself and response to treatment.

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Wound Measurement Guidelines

Measurement of wound size is an important nursing assessment because wound size changes over time and is used to
indicate healing or negative progression. Since wound measurement is an assessment, it cannot be delegated to
unlicensed assistive personnel (UAP).
The metric system is used when measuring wounds with facility-provided disposable rulers that have centimeter or
millimeter increments. Sterile cotton-tipped applicators can be used to measure the depth of a wound. This table
illustrates the steps involved in measuring a wound:

Dimensions

 Measure width laterally from the left to right sides at the widest open area of the wound.
 Measure length vertically from the top to the bottom, or head to toe, at the widest open area of the wound.

Depth

 Measure depth of the visible wound by inserting the tip of a sterile cotton-tipped applicator straight down into
the deepest part of the wound.
 Mark the area on the stick portion of the applicator that is even with the level of the skin.
 Measure the distance from the tip of the applicator to the marked area on the stick to determine the depth of
the wound.

Undermining

 Measure depth of undermining by laterally inserting the tip of a sterile cotton-tipped applicator into the widest
section of the undermining.
 Mark the area on the stick end of the applicator that is even with the edges of the skin, and measure the
distance from the tip of the applicator to the marked area to determine the depth of the undermining.
 Measure tunneling the same way.
 Be sure to insert the sterile cotton-tipped applicator gently. The patient may require pain medication before the
procedure.

Documentation

 Documentation is the last step involved in wound measurement. Document:

o Color of wound bed and periwound area; amount, color, consistency, and odor of drainage; and type of
issue present in wound.
o Any signs or symptoms of infection. Measure any changes in the skin surrounding wound that may
indicate infection.
o All measurements by width, length, depth, and undermining depth in metric units, such as cm or mm.
o Where the undermining measurements were taken within wound.
 Consider including a drawing or photograph, if necessary, to fully document shape of wound.
 Any patient pain or discomfort stated by the patient during the procedure.

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 Sherpath Ch. 48 Skin Integrity and Wound Care

In addition to assessment and documentation of wounds to determine their progression toward healing, there are tools
that also help nurses track wound healing over time.
Examples include:
1. Wound Characteristic Instrument: Used to assess open wounds.
2. Pressure Sore Status Tool (PSST): Assigns a numerical score based on 13 wound attributes.
3. Pressure Ulcer Scale for Healing (PUSH): Assigns a numerical score based on three characteristics.
Scores obtained from the serial observations of wounds from the PSST and PUSH allow healthcare providers to track
wound healing, more rapidly identify trends that may be positively or negatively affecting wound healing, and revise
treatment plans when negative trends are identified.

Key Points
 Every patient, in every clinical setting, should receive a thorough skin assessment.
 Skin assessment should include focused physical examination and focused health assessment questions.
 When wounds are present, a more detailed assessment of the wound is required to help determine treatment
and serve as the baseline for evaluating treatments and healing.
 The Braden Scale uses sensory perception, moisture, activity, mobility, nutrition, and friction and shear as
categories for predicting pressure ulcer risk.
 The Norton Scale uses the patient’s physical condition, mental state, activity, mobility, and continence as
categories for predicting pressure ulcer risk.
 A focused wound assessment includes inspection and examination of the wound’s location, size, and color;
presence of drainage; condition of the wound edges; characteristics of the wound bed; and patient’s response to
the wound or wound treatment.
 Documentation of wound characteristics and changes is important to determine wound healing or the need for
treatment revisions when wound healing does not occur.
 Tools useful for tracing wound healing include the Wound Characteristic Instrument, Pressure Sore Status Tool
(PSST) and Pressure Ulcer Scale for Healing (PUSH) tool.

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