Wound Assessment in 60 seconds

Wound Assessment in 60 seconds

Use the acronym CLOSE UPP

Color - use percentage to describe the amount of slough, granulation tissue, etc)
Location - where is it? right side, left side, midline?
Odor - what smells do you notice?
Size - measure largest points for length, width, and depth
Edema / exudate - swelling and oozing (serous, serosang, sang, purulent) - note amount and color, and mark edges of edema with a pen

Undermining / tunneling - check to see if there is more wound than you can see
Periwound area - is it healthy and intact, indurated (hard), macerated (moist and white), edematous
Pain _ don't forget a pain assessment (PQRSTU), and do a pain scale pre, during and after procedure to identify changes

Nursing students, nurses, and other health care professionals must gather this data when completing any wound assessment to document changes over time and to capture a would that is not healing faster to prevent serious and potentially permanent changes.

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