A systematic description of the wound bed is essential for effective wound management. This standardized assessment allows healthcare providers to accurately track whether the wound is progressing toward healing or deteriorating. By consistently documenting the wound’s characteristics, clinicians can communicate its status clearly across different care settings and determine the most appropriate treatment plan. The systematic process breaks down the complex visual presentation of a wound into distinct, measurable components: size, tissue type, drainage, and surrounding skin integrity.
Assessing the Dimensions of the Wound
The initial step in describing a wound involves measuring its size to establish a baseline for tracking progress. Standard measurements include the wound’s length, width, and depth, all recorded in centimeters. Length is measured from the patient’s head to toe at the longest point, while the width is measured at the widest point perpendicular to the length measurement.
Depth is determined by gently probing the deepest visible area of the wound base using a sterile applicator. Measurements are oriented using the “clock face” method, where the patient’s head corresponds to the 12 o’clock position and the feet to the 6 o’clock position. This orientation is important when assessing for complex features like undermining and tunneling.
Undermining describes tissue separation that occurs beneath the wound edge, creating a lip or shelf parallel to the skin surface. Tunneling (or a sinus tract) is a narrow channel or passageway that extends from the wound base into deeper tissue layers. Both are measured by inserting a sterile probe and noting the depth and the clock-face position where they occur, indicating areas of tissue destruction that require specific packing to promote healing.
Identifying Tissue Types and Colors
The appearance of the tissue within the wound base provides evidence of the biological processes occurring and is a central element of the assessment. Wounds often contain a mix of tissue types, quantified by estimating the percentage of the wound bed each type occupies. These tissues are classified by color, which indicates their viability and healing status.
Granulation tissue is the healthy, regenerating tissue that signifies the wound is advancing toward closure. It has a beefy red or pink color and a moist, bumpy texture due to the formation of new blood vessels. Conversely, slough is non-viable tissue that appears soft, stringy, and yellowish, whitish, or tan. Slough impedes healing by harboring microorganisms and keeping the wound in a prolonged inflammatory state, often requiring removal.
Eschar is non-viable tissue, appearing as hard, leathery, dark brown or black tissue. It results from tissue death and can be firmly attached to the wound base. Epithelialization represents the final stage of wound resurfacing, where cells migrate inward from the wound edges. This new skin layer appears as a pale pink or pearly color, often with a fragile, shiny texture, covering the healthy granulation bed.
Characterizing Exudate (Drainage) and Odor
Wound exudate, or drainage, is the fluid produced by the wound, and its characteristics offer insight into the wound’s biological state, particularly concerning infection and moisture balance. The amount of exudate is described by classifying the saturation level on the dressing as none, scant, small, moderate, or copious. An excessive volume of drainage can delay healing and damage the surrounding skin.
The color and consistency of the drainage further refine the assessment.
- Serous exudate is thin, clear, or straw-colored, considered normal in a healing wound.
- Sanguineous drainage is thick and bloody, often seen in fresh injuries or when tissue has been traumatized.
- Serosanguineous is a mixture of these two, which is a thin, watery, pink-red fluid.
- Purulent drainage is thick, opaque, and typically yellow, green, or brown, often associated with infection.
A distinct odor may accompany the exudate, which is noted as present or absent and described (e.g., foul or sweet). While odor can be caused by necrotic tissue, a foul odor combined with purulent drainage frequently signals a high concentration of bacteria, necessitating medical evaluation.
Evaluating the Periwound Skin
The systematic description focuses on the periwound skin, which is the intact skin immediately surrounding the wound edge. Assessing this area helps determine if the dressing regimen is functioning optimally or if secondary issues are developing that could impede healing. The condition of this skin can be compromised by excessive moisture or signs of localized inflammation.
Maceration is a common sign of excessive moisture, where the skin becomes softened, white, and fragile, making it highly susceptible to breakdown. Erythema, or redness, suggests increased blood flow, which can indicate inflammation or a localized infection. The severity of the erythema helps to differentiate between normal healing inflammation and a spreading infection.
Induration is a hardening or firmness of the periwound tissue felt upon palpation, which can be a sign of deep tissue inflammation or infection. Edema, or swelling, indicates fluid accumulation in the tissue, often measured by its extent or whether it is pitting. These periwound characteristics are important indicators that the moisture balance, dressing selection, or infection control measures may need adjustment.