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Wound Assessments

These Wound Assessment guidelines meet the requirements for Medicare/Medicaid OASIS and are endorsed by the Wound and Ostomy Nurses Organization.

  1. Location-can give clues as to the cause. For example: trochanteric (bony prominence at the upper end of femur) indicates pressure from a side lying position, ischial (lower portion of hip bone) and sacral indicate pressure from sitting.
  2. Shape---triangular, linear, etc.
  3. Size-measure length, width and depth. All measurements should be done with the patient in the same position on each visit. Measure length from head to toe. Measure width from hip to hip. To measure depth, moisten a sterile cotton tipped applicator with 0.9% sodium chloride. Place applicator tip in the deepest aspect of the wound and measure the distance to the skin level. If the depth is uneven, measure several areas and document the range and which part is the deepest. Document all measurements in cm.
  4. Undermining: Assess by inserting a sterile Q-tip moistened with 0.9 Sodium Chloride under the edge of the wound advance as far as it will go without using undue force. Measure the distance to the skin level. Document all measurements in cm.
  5. Drainage:
    • A: Type
      • Bloody-thin, bright red
      • Serosanguinous---thin, watery, pale red to pink
      • Serous---thin, water, clear (indicates infection)
      • Purulent---thin or thick, opaque tan to yellow (indicates infection)
      • Foul purulent---thick, opaque yellow to green with offensive odor (indicates infection)
    • B: Amount:
      • None-wound tissues dry
      • Scant---wound tissues moist, no measurable drainage
      • Small-wound tissues wet, moisture evenly distributed in wound, drainage involved 25% of dressing
      • Moderate---wound tissue saturated, drainage may or may not be evenly distributed in wound, drainage involved 25% to 75% of dressing
      • Large---wound tissues bathed in fluid, drainage freely expressed, may or may not be evenly distributed in wound, drainage involves 75% of dressing
  6. Description of Wound:
    • Stage I intact skin with non-blanchable redness of a localized area usually over a bony prominence
    • Stage II: Partial thickness involves loss of the epidermis and dermis. Presents as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured blister.
    • Stage III Full thickness without appearance of tendon, muscle or bone but may have exposure of subcutaneous tissues
    • Stage IV Full thickness with tendon, muscle, bone exposure----involves damage to the subcutaneous tissue, muscle and bone.
    • Granulation---tissue includes new blood vessels, pink then turns to red.
    • Slough---moist, yellow to tan.
    • Eschar---dry, dead tissue, dark brown or black.
  7. Wound Status:
    • Fully Granulating: wound bed filled with granulation tissue to the level of the surrounding skin or new epithelium, no dead spaces no eschar &/or slough, no signs/symptoms of infection, wound edges are open
    • Early/Partial Granulation: 25% of the wound bed is covered with granulation tissue, there is minimal exchar &/or slough, may have dead space, no signs/symptoms of infection, wound edges open
    • Not Healing: wound with 25% eschar &/or sloughing OR signs/symptoms of infection, clean but non-granulating wound bed OR closed/hyperkeratotic wound edges OR persistent failure to improve despite appropriate comprehensive wound management.
    • Note: A new Stage 1 pressure ulcer is reported on Medicare/Medicaid Oasis as "Not Healing".

Full and exact wound assessments are to be completed weekly for all clients. Documentation of procedures is done each time the nurse performs the procedure. MD should be notified of the first signs or symptoms of infection and for deterioration of a wound. An incident report is completed for a worsening of a decubitus ulcer or infection of a wound that was not present at admission despite notification to the physician.

There must be a physician's order for all necessary dressings and products used on the wound. Instructions given to the client at each visit are do be documented including nutritional, infection control, pressure relief, procedural instructions, importance of proper hydration, S&S to report to the MD.




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