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Assessment of the Wound

ASSESSMENT OF THE WOUND

Wound Bed

Granulating:  Granulation tissue is deposited during the repair process. It appears pinkish - red and moist. It comprises newly formed collagen, elastin and capillary networks. The tissue is highly vascular and bleeds easily.

Epithelialising: Epithelial tissue appears whitish-pink. During this phase the wound surface is covered by new epithelium, a process that occurs only after the wound has filled with healthy granulation tissue.

Sloughy: This is devitalized yellowish tissue. It is the accumulation of dead cells.  This is not to be confused with pus.

Necrotic: This is dead tissue. It presents as hard, dry and black. The presence of dead tissue in a wound prevents healing and must be removed.

Hypergranulating: This occurs when granulation tissue grows above the wound margin. It is a prolonged proliferative phase of healing, usually as a result of bacterial imbalance or irritants.
 
Wound Measurement
It is always useful to keep either a graphical wound measurement, descriptive wound measurement or photographic image to monitor wound healing.
 
Wound Edges
Healthy wound edges have epithelium growing over mature granulated tissue. 
Consider these 5 features:
  1. Colour – Review the colour of the wound edges. Pink edges indicate growth healthy tissue; dusky edges indicate hypoxic damage and erythema indicates inflammatory response or infection.
  2. Raised - Is the wound margin is elevated above the surrounding tissue? It may indicate pressure, trauma or malignant change.
  3. Rolled – Look for rolled edges. When rolled down towards the wound bed, the edges tend to indicate wound stagnation and chronicity.
  4. Contraction – Is there contraction of the wound edges? If there is it is a clear sign of healing.
  5. Sensation - increased pain (infection) or the absence of sensation (nerve damage) should be noted.  
Infection
Is there presence of bacteria or other organisms? This can lead to redness, increased amounts of exudate. The exudate often has changes in its colour. There may be malodour, pain and heat. It leads to delayed healing and wound breakdown.
 
Surrounding Skin
Review the surrounding skin to identify the following:
  • Healthy tissue
  • Maceration
  • Dry or flakiness
  • Eczematous
  • Black/blue discoloration 
  • Fragility
  • Oedema or redness

  • Induration or cellulitis


Cellulitis
Any cellulitis needs to be treated in conjunction with wound management. 

Pain

Accurate assessment of pain is in useful choosing the most appropriate dressing.

Exudate

Is produced by all wounds, it is an essential part of the healing process containing growth factors and nutrients. It cleanses the wound, provides the moist environment essential for proper healing.  It has a major role in promoting epithelialisation. It is paramount to monitor the type, quantity and odour of any wound to identify new changes.

Too much exudate leads to maceration with degradation of skin, while too little can result in the wound bed drying out. It may become thicker and odorous in infected wounds.

The exudate may be:

Type Colour Consistency Significance
Serous Clear Straw coloured Thin, watery Normal. An increase may be indicative of infection
Haemoserous Clear, pink Thin, watery Normal
Sanguineous Red/bloody Thin, watery Trauma to blood vessels
Purulent Yellow, brown, grey, green Thick Indicative of infection
Other Factors

There are other factors that must be considered as they can delay wound healing for example:

  • Malnutrition
  • Impaired blood flow
  • Medications
  • Emotional stress
  • Oedema 
  • Infection
  • Maceration
  • Systemic illnesses such as diabetes and autoimmune disorders
  • Patient compliance
  • Pressure
  • Immobility