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wound assessment
Clinical manifestations:
- location
- wound size & shape, length, width, depth
- pressure ulcer staging (see pressure ulcer assessment)
- grading of diabetic foot ulcer
- wound bed
- color
- presence of slough, necrotic tissue, granulation tissue, epithelial tissue
- underminining or tunneling
- exudate: purulent vs non purulent, serous, serosanginous
- edges: distinct, diffuse, rolled under
- periwound skin & soft tissue: erythema, edema, induration, temperature
- presence of pain at rest & with wound care procedures
- signs of wound infection
- necrotic tissue
- foul odor
- purulent exudate
- erythema at wound edges
- pain
- edema
- friable granulation tissue
- non healing or enlarging wound
- heat
Laboratory:
- see wound culture
Specific
pressure ulcer assessment
General
clinical procedure
References
- Geriatrics at your Fingertips, 13th edition, 2011
Reuben DB et al (eds)
American Geriatric Society