Wound Assessment Principles

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Wounds Clinical reference

Wound Assessment Principles

Systematic wound assessment: location, size (L×W×D), tissue type (granulation/slough/necrotic/eschar), wound edges, exudate (type/amount), peri-wound skin, pain. TIME framework: Tissue, Infection/Inflammation, Moisture, Edge.

wound assessment wound evaluation wound measurement TIME wound framework
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Latest evidence

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Common tests

Tests performed

Wound measurement (ruler or planimetry) Wound culture (if infection suspected — swab or tissue biopsy) Nutritional assessment (albumin, prealbumin) Vascular assessment (ABI for lower extremity) Braden scale (pressure injury risk)
Common medications

Recognize the drug and the class

Wound cleansing: Normal saline (preferred) or wound cleanser Debridement: Sharp (fastest), enzymatic, autolytic, biological (maggot therapy) Moisture balance: Hydrocolloid, foam, alginate, hydrofiber Antimicrobial: Silver-containing dressings (infected/critically colonized)
Related nursing diagnoses

NANDA diagnoses & care plans

Use these direct links to open nursing diagnoses and care-plan support related to Wound Assessment Principles.

Impaired Tissue Integrity Impaired Skin Integrity Risk for Infection Imbalanced Nutrition