wound assessment
Tissue
wound bed
pain
measurment
two dimansional -------------- width / lenth
epithilializing
sloughy
necrotic
hypergranulating
red to pink
pink to white
yellowish
grey, black, hard
tissue grows above wound margin
granulating
three dimansional ------------ depth
wong baker #
numerical #
pain ........ Before / During / After
Infection
local
systemic
Moisture
exudate
dry
moist
too moist
wound by drying out
⬆ epitheliali
exudate:
nutrients, energy& growth factor for metabolizing cells
⬆ WBC
- cleanses wound
- maintain
- promote epithelization
Edges
pink --- growth of new tissue ✅
dusky -------- hypoxia ❎
erythema------inflamatory response or cellulitits
contracting ----- cormng together
Skin suroundings
healthy