Describing wound details

Describing the details

Wounds are described as either partial or full thickness. A partial-thickness wound involves tissue damage to the epidermis and dermis. A full-thickness wound involves damage to the subcutaneous tissue, muscle, and bone. Various classification systems have been designed to help you assess specific wound types, document accurately and completely, and gauge healing. (See Definitions for Pressure Ulcers and Wagner's Foot Ulcer Grade Classification.)

In addition to general wound characteristics, examine what's in and around the wound to further assess it.

Type of tissue. Although a healthy fully granulating wound bed is ideal, many wounds consist of varying amounts of healthy granulation tissue and nonviable tissue, such as slough or eschar. Granulation tissue includes new blood vessels and immature collagen. Initially pink, it turns beefy red as it accumulates. Slough is moist, devitalized tissue that may adhere strongly or loosely to the wound bed and walls. The color normally ranges from yellow to tan. Eschar is dry, dead tissue that's dark brown or black. As tissue damage continues, eschar usually thickens and attaches more firmly to the wound.

As you identify the types of tissue in the wound bed, estimate how much of each is present, such as 60% granulation, 20% slough, and 20% eschar. Document the percentages on a flow sheet to allow for assessment of wound healing or deterioration.

* Wound integrity. If your patient has a fullthickness wound, assess for undermining, a hollow between the skin surface and the wound bed that occurs when necrosis destroys the underlying tissue. wTunneling, on the other hand, is a passageway within and beyond the wound walls or base.

To document undermining or tunneling, relate its location to a clock, with 12 o'clock toward the patients head. For example, "Undermining of 4 cm from the 2 o'clock to the 6 o'clock position" or "The wound tunnels 6 cm at the 5 o'clock position."

Next, examine the wound for the presence of supporting structures, such as tendons or bones. Note any orthopedic hardware and be alert for foreign bodies, such as sutures and staples, all of which increase infection risk. Wounds with tunneling or undermining are especially vulnerable for retained dressings. Lastly, assess for foreign bodies, such as a forgotten suture or lint.

* Exudate. Follow your facility's guidelines for defining "small," "moderate," and "high" amounts. Describe the exudate as serous, serosanguineous, or purulent. Infection can affect the color, consistency, and amount of exudate as well as cause an odor.

* Wound edges. In full-thickness wounds, particularly when undermining is present, the edges may curl under and delay healing. A white, shiny appearance at the wound edges may be the result of epidermal cells migrating across the wound to resurface it, which signals healing.

* Periwound skin. Assess the skin around the wound for color, moisture, intactness, induration, edema, pain, and presence of a rash, trophic skin changes, and infection. The color can be pink, red, blue, pale white, or gray; in darker skin, you may note deeper skin tones. Pink usually indicates healthy skin; red may indicate friction, pressure, or beginning infection; blue or pale white is often a sign of compromised circulation. Erythema may or may not blanch when you apply pressure.

The skin surrounding a wound may have too much moisture (maceration), which could increase the patients risk of fungal or yeast infection. Assess the periwound skin for primary skin lesions. Note the presence of a hyperkeratotic rim (a calluslike growth), often associated with neuropathic wounds on a weight-bearing surface. Infection of the periwound tissue often presents with erythema; induration; warmth; change in the color, odor, or consistency of the exudate; and pain.

For more information regarding wound assessment and for a complete wound measuring and documentation solution please visit www.woundassessment.co.uk