Get the WOUND PICTURE

In the course of an initial wound assessment, a picture of the patient, the patient's environment, and the wound's characteristics and healing status emerges. This will play an important role in wound monitoring and serve as a benchmark for wound healing.

Use the mnemonic device WOUND PICTURE to help recall and organize the key facts that should be included in documentation:

W ound or ulcer location

O dor? (constantly pervading the patient room or only when the wound is uncovered?)

U lcer category, stage (for pressure ulcers) or classification (for diabetic ulcers), and depth (partial-thickness or full-thickness)

N ecrotic tissue?

D imension of (length, width, depth, shape); D rainage color, consistency, and amount (scant, moderate, large)

P ain? (when it occurs, what relieves it, and the patient's description and rating on a scale of 0 to 10)

I nduration? (surrounding tissue hard or soft)

C olor of the wound bed (red, yellow, black, or a combination)

T unneling? (length and direction; specify whether it travels to the left or right or toward the head or feet)

U ndermining? (length and direction; use clock-face references in the description)

R edness or other discoloration in surrounding skin?

E dge of skin (loose or tightly rolled? edges flat or rolled under?)

Adapted from Wound Care made Incredibly Easy!! Springhouse, PA: Lippincott Williams & Wilkins; 2003. p 42.