Accurately describing a wound bed provides important information for effective communication and monitoring healing progress. This guide focuses on key observations to understand a wound’s condition and determine if professional medical attention is necessary.
Observing the Wound Bed Tissue
The appearance of the tissue within the wound bed provides insights into the healing process. Different tissue types indicate varying stages of healing.
Healthy granulation tissue typically appears red or pink with a moist, bumpy, or “cobblestone-like” texture. This tissue contains new blood vessels and connective tissue, filling the wound from the bottom up. Its vibrant color comes from the rich blood supply.
In contrast, other tissue types can impede healing. Slough is dead tissue that appears yellow, tan, or white and can have a soft, moist, or stringy texture. It may be loosely or firmly attached to the wound bed. The presence of slough can attract bacteria, potentially leading to infection and delaying healing.
Another type of non-viable tissue is eschar, which is dry, hard, and typically black or brown. It is firmly attached to the wound bed and hinders healing.
Epithelial tissue, signifying the final stage of wound closure, appears as new, delicate, light pink or pearly tissue forming from the wound edges. This tissue gradually covers the wound.
Assessing Wound Drainage
Wound drainage, also known as exudate, offers clues about the wound’s status, including inflammation and potential infection. The color, consistency, amount, and odor of this fluid are all important observations.
Serous drainage is clear to pale yellow and has a thin, watery consistency, similar to plasma. This type of drainage is often seen in small amounts during the initial inflammatory phase and is a normal part of healing.
Serosanguineous drainage is a mix of serous fluid and blood, appearing thin, watery, and typically pink or light red. This color comes from a small number of red blood cells and is commonly observed in the early stages of healing, indicating minor capillary damage.
Sanguineous drainage is primarily fresh blood, characterized by a bright red color and a somewhat thick, syrupy consistency. It is expected immediately after an injury or surgery during the inflammatory phase, though its volume should decrease over time.
Purulent drainage is a sign of potential infection and is never considered normal. It is thick, milky, and opaque, often appearing yellow, green, tan, gray, or brown. This type of drainage contains white blood cells, dead bacteria, and tissue debris, and frequently has a foul or unpleasant odor.
The amount of drainage can be described as none (dry), scant (moist, no measurable amount on dressing), minimal (less than 25% of dressing covered), moderate (25-75% of dressing covered), or copious (more than 75% of dressing covered). Excessive drainage, particularly if purulent, suggests a problem.
Examining Wound Edges and Surrounding Skin
The appearance of the wound edges and the surrounding skin provides additional information about healing and potential complications. Wound edges can be described based on their attachment and appearance.
Attached edges mean the wound edges are level with the wound bed, which is a positive sign for healing. Conversely, unattached or rolled edges, also known as epibole, where the skin rolls inward, can hinder wound closure.
Macerated edges, which appear white, soft, and wrinkled, indicate prolonged exposure to moisture, often from excessive wound drainage, weakening the skin and delaying healing.
The skin immediately surrounding the wound, known as the periwound area, should also be examined for changes. Redness, or erythema, can indicate inflammation or infection, particularly if it is spreading or accompanied by warmth.
Swelling, or edema, suggests fluid accumulation and can impede blood flow and oxygen delivery to the wound. Other observations include pallor (unusual paleness), dryness, or a rash, which can signal underlying issues affecting healing.
Measuring and Documenting Wound Dimensions
Quantifying wound dimensions is a practical step to monitor progress and identify any changes. The length, width, and depth are standard measurements.
Length is typically measured from “head to toe” at the longest point, while width is measured perpendicular to the length at the widest point. These measurements are usually recorded in centimeters.
For depth, a sterile cotton-tipped applicator can be gently inserted into the deepest part of the wound, marked at skin level, and then measured against a ruler.
Documenting these measurements consistently over time provides a clear record of the wound’s trajectory. A decrease in length, width, or depth generally indicates healing progress. Conversely, an increase in size could signal a setback or a worsening condition.