A complete wound assessment addresses each of the following for every wound, every visit, and compares each finding to the prior visit.
Etiology — classify the wound (pressure, arterial, venous, neuropathic/diabetic, surgical, skin tear, moisture-associated); etiology drives the treatment plan and the offloading or compression decision.
Stage — NPIAP stage for pressure injuries (1–4, unstageable, deep-tissue injury); for non-pressure wounds, depth and tissue type.
Measurement — length × width × depth in centimeters, plus undermining and tunneling located by clock position, using a consistent technique and orientation.
Wound bed — percentage of granulation, slough, and eschar; whether the base is improving or declining.
Exudate — amount (scant, moderate, large), type (serous, sanguineous, serosanguineous, purulent), and odor.
Periwound and edges — erythema, maceration, induration, warmth, callus, epibole, and the width of any surrounding erythema.
Infection signs — increasing erythema, warmth, purulence, odor, new or increasing pain, fever, and delayed healing (local vs spreading vs systemic).
Pain — at rest and with dressing changes, on a validated scale, and its change from baseline.
The current dressing and offloading or compression in place — whether it matches the order and remains appropriate.
Healing trajectory — the direction of change since the last visit and whether the plan should continue or be revised.
