• Dimensions: Includes length, width, and depth. 
  • Measurements are important.
  • Record all measurements in centimeters.
  • Use the same tool for measuring to ensure accuracy. 
  • Wound width is simply the longest distance across the wound at a right angle to the length. 
• Depth: Includes tunneling and undermining (check with wound care specialist of the current procedure being used in the facility to measure depth and tunneling).
  •  Measure the depth with a foam-tipped device or a cotton-tipped swab, Cotton fibers could be left in the wound and the rigid cotton tip may cause trauma to the wound.
  • Gently insert the device into the deepest portion of the wound and then carefully mark the stick. 
  • Remove the device and measure.
  • Do not probe surgical wounds.
• Texture: Healthy granulation tissue has a soft , bumpy appearance.
  • Eschar is wound (dead) tissue that is characterized by a dry leathery, black crust.
  • Slough is non viable tissue that is loosely attached, appears stinglike, moist, yellow, green, or gray in color. 
• Margins and Surrounding skin:
  • Measure and record areas of reddened intact skin and white skin as surrounding erythema and maceration. 
  • Maceration is the softening of a solid as it's soaked in fluid ( in wounds, maceration is indicated by whitened tissue)
• Drainage descriptions: Color and consistency:

1.      Serous, clear or light yellow, thin and watery.
2.      Sanguineous, Red (with fresh blood) thin.
3.      Serosanguineous, pink to light red, thin and watery.       
4.      Purulent, Creamy yellow, green, white, or tan, thick and opaque. 

Wound healing isn't a simple matter to coordinate.  Success is more likely with vigilance and consistent assessment and documentation.
 
Documentation as well as communication to the Health Care Team is an important aspect of wound monitoring. Notify the Physician or Wound Care Specialist with any changes noted within the wound.