How to structure a wound assessment?

Wound assessment should be comprehensive and person-centered. It should include the following three components:  

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1. General patient assessment

Past medical history / Comorbidity / Medication / Mobility and Dexterity / Nutrition and Hydration / Pain levels / Psychological and Social impact of wound, the patient’s understanding of their condition, expectations and desired outcomes. / Social environment of the patient including the level of caregivers and family support

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2. Specific lower limb assessment (i.e. Leg ulcers)

Leg-skin condition / Oedema (present or not, where, what type, how much) / Ankle circumference / Leg  shape / Patient mobility and ankle flexion / Patient-reported pain / Ankle Brachial Pressure Index (APBI) / Foot pulses (presence or absence of)...

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3. Wound assessment

Location / Duration / Size, depth and shape (measure the wound) / Type of tissue on the wound bed / Signs of local infection / Exudate level and type / Condition of the wound edges and of the peri-wound skin.  

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DID YOU KNOW? Palpation of pulses

There are two major foot pulses: the dorsal pedal-artery on the dorsum of the foot and the posterior tibial artery behind the medial malleolus. Absence of both pedal pulses on one foot strongly suggests that vascular disease is present. As such, it is possible to initially screen for the presence of vascular disease and ischaemia by simple pulse palpation, which requires no equipment:

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Bianchi J, Flanagan M, King B. 3D: a framework to improve care for patients with leg ulcers. Implementing person-centred diagnosis, evidence-based treatment decisions and inclusive dialogue with the 3D framework. J Wound Care 2020; 29 (11 Suppl a):S1–S66