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