Wound assessment: bed, edges, exudate and signs of infection

What it is

Assessing a wound means looking at and measuring the same things at every dressing change: where it is and what type it is, how much tissue is damaged, what the wound bed looks like, how much and what kind of exudate there is, its size, its edges and the skin around it, signs of infection and pain. If every clinician measures the same way, comparing dressing changes shows whether the wound is moving toward healing. Assessment guides the dressing, but it does not replace the medical diagnosis of the cause.

Reference values

• Scant exudate: the bed is moist, but no exudate shows on the dressing.
• Minimal exudate: covers less than 25 % of the dressing.
• Moderate exudate: covers 25 % to 75 % of the dressing.
• Large exudate: covers more than 75 % of the dressing.
• Types of exudate: serous (clear and thin), serosanguineous (serous with a little blood), sanguineous (fresh blood) and purulent (thick and opaque).

What you need

• Clean gloves and, if splashing is likely, eye protection.
• A disposable ruler or measuring guide and sterile cotton-tipped applicators for tunnels and undermining.
• Good lighting and the previous wound record for comparison.
• The unit's pain scale.

How to measure it (and why)

1. Assess pain before removing the dressing and give ordered analgesia if needed — dressing pain is easier to prevent than to treat.
2. Record the location in anatomical terms and the wound type — with several wounds it avoids mix-ups and points to the cause.
3. Look at the bed: granulation, slough, eschar, tunnelling — the tissue type shows the phase of healing.
4. Measure length (head-to-toe axis) by width and the depth, the same way as last time — measuring the same way allows comparison.
5. Probe tunnels and undermining with a sterile applicator, never forcing, and locate them as a clock (12 toward the head) — not forcing avoids damage.
6. Describe exudate by amount, type and odour — a change in exudate is one of the first signs of infection.
7. Check edges and surrounding skin: approximation, dehiscence, maceration, redness — the surrounding skin shows excess moisture or infection.
8. Record everything with date and time and compare with the previous assessment — the trend shows whether the plan works.

How to read it

• A shrinking wound with pink granulation and scant serous exudate: expected progress.
• Macerated edges (white, soft, wet): too much moisture; review the dressing and how often it is changed.
• A primarily closed wound whose edges have separated: dehiscence.
• Increasing pain, spreading redness, induration or odour: probable local infection.
• Pain does not always match the damage: a diabetic foot ulcer with neuropathy may hurt little.

Next step: when to call for help

• Report new purulent exudate, odour or spreading redness; a culture may be needed.
• Report new slough or eschar, tunnels and undermining.
• Report at once dehiscence of a surgical wound, active bleeding or fever.
• Ask for the wound care team when the wound does not improve between dressing changes.

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Nursing Skills, 10.3: Assessing Wounds (Open RN, Chippewa Valley Technical College (via LibreTexts), 2021); Nursing Skills, 10.2: Basic Concepts Related to Wounds (Open RN, Chippewa Valley Technical College (via LibreTexts), 2021).

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