Wound Care

Wound Assessment Model

Wound assessments provide the foundation of the plan of care and are the only means of determining the effectiveness of the interventions. For further information regarding skin assessment, prevention and treatment of pressure injury sites/wounds, please refer to your unit’s “Wound Care Wall”.


Wound Assessment and Treatment Information

What does the Wound Bed Look Like?

Granulation tissue (red)
Fibrin slough (yellow)
Eschar (black)
Other underlying structure

Some or all of these tissues and structures may be present in the wound at one time, a diagram of the wound bed that shows location and amount of tissue or structures will help assess healing processes.

At Windsor Regional Hospital, wounds are measured documenting length, width and depth (if applicable). Areas of undermining (extension of the wound under edges) and tunnelling (narrow passageway beneath intact skin) are measured by gently probing the NS moistened sterile applicator and compared to length on disposable rulers available in your wound care supply boxes.

How do you Measure a Tunneled Wound?

  1. Gently insert the normal saline moistened cotton-tipped applicator into the sites where tunnelling occurs
  2. View the applicator as if it were a hand of a clock (12 o'clock lines up with the patient's head)
  3. Progressing in a clockwise fashion, document the deepest sites where the wound tunnels (for example, "3 o'clock")
  1. Gently insert the cotton-tipped applicator into the tunnelling areas
  2. Grasp the applicator where it meets the wound's edges
  3. Pull the applicator out, place it next to a measuring guide, and document the measurement (in centimetres).
Percentages (%) can indicate approximate amounts of different tissue types in the wound (eg 50% eschar 50% red)

Is the Wound Infected?

Symptoms that may occur in an infected wound:

Local Signs & Symptoms  Systemic Signs & Symptoms 
PAIN Fever
Peri-wound skin is reddened Malaise
Peri-wound skin is warm to touch Increased WBC
Peri-wound skin or limb is edematous *N.B. To suspect an infection, most local and systemic S&S listed here need to be present. Reddened peri-wound skin and fever only may be a sign of the inflammatory phase of healing
Peri-wound skin is indurated (hard) or boggy
Purulent drainage (green, yellow...)
Drainage has a foul odour

Swabbing the wound is essential to ensure that the correct antibiotic is being administered.

When obtaining a swab:

  • Only swab if the wound APPEARS infected
  • The wound bed should be well cleansed with saline to avoid contamination of swab by surface organisms
  • Do not swab eschar, exudate or pus
  • Select the cleanest area of the wound
  • Firmly press and rotate swab in this area
  • Include tunnelling if present
  • Treating the infected wound
  • Treatment of infected wounds should be done in consultation with the physician
  • Systemic antibiotics (use only when definitive diagnosis has been established)


Wound Care Products