Advanced Wound Assessment
1. Patient & Clinical History
Comorbidities (diabetes, vascular disease, renal disease, malnutrition)
Medications (steroids, anticoagulants, chemotherapy)
Mobility level and pressure risk
Previous wound treatments and response
Pain assessment
2. Wound Etiology Identification
Determining the cause of the wound is critical:
Diabetic foot ulcers
Venous leg ulcers
Arterial ulcers
Pressure injuries
Surgical wounds
Traumatic wounds
Atypical wounds (vasculitic, malignant, inflammatory)
3. Wound Measurement & Documentation
Length, width, and depth
Tunneling and undermining
Wound volume (when applicable)
Serial measurements to track healing progress
4. Tissue Assessment (Wound Bed)
Granulation tissue
Slough
Eschar
Necrotic tissue
Epithelialization
5. Exudate Evaluation
Amount (none, scant, moderate, heavy)
Type (serous, sanguineous, purulent)
Odor (before and after cleansing)
6. Periwound Skin Assessment
Maceration
Erythema
Induration
Callus formation
Signs of dermatitis or infection
7. Infection & Biofilm Assessment
Local signs: redness, warmth, swelling, delayed healing
Systemic signs: fever, elevated WBC
Consideration of biofilm presence
Culture when clinically indicated
8. Perfusion & Vascular Assessment
Palpation of pulses
Capillary refill
Ankle-Brachial Index (ABI)
Toe pressures or TcPO₂ when needed
9. Pain & Sensory Assessment
Neuropathy evaluation
Ischemic vs inflammatory pain
Impact on quality of life
10. Advanced Diagnostic Tools (as indicated)
Digital wound imaging
Fluorescence imaging for bacterial burden
Ultrasound or MRI (osteomyelitis suspicion)
Laboratory markers (albumin, prealbumin, HbA1c)
Why Advanced Wound Assessment Matters
- Identifies barriers to healing early
- Reduces infection and hospitalization risk
- Guides evidence-based treatment plans
- Improves healing outcomes and patient quality of life
- Ensures regulatory and documentation compliance