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WOUND ASSESSMENT (WOUND BED (Sloughy (yellow) (Usually moist, soft,…
WOUND ASSESSMENT
WOUND BED
Sloughy (yellow)
Usually moist, soft, stringy, present in clumps, separates itself from the wound bed
Granulating (red)
Light red or pink, bumpy appearance, moist, healthy and indicates an attempt to provide a new protective layer
Eschar (scab)
Usually black and dry, result from tissue necrosis or death, may be firmly adhered to wound or lifting, may appear scab like
Epitheliasing (Pink)
New skin, light pink, normally indicates wound recovery
Necrosis (black)
Usually dark tissue, forms as a result of tissue death from damage, should be debrided to allow healing
Biofilm
stimulates inflammation, may present as slough, form of infection made up of living microbes
Non Viable Tissue
Wound bed may be covered with necrotic tissue, slough or eschar leading to impeded healing
Hypergranulation
excess of granulation tissue that fills wound bed, resulting in a raised tissue bed
EXUDATE
Wet
Small amount of visible fluid, dressing extensively marked, no strike through, increased dressing change frequency
Saturated
Visible free fluid when dressing removed, primary dressing wet, strike through occurs
Moist
Aim of exudate management, small amounts of visible fluid when dressing removed, may look glossy, skin likely to be intact, hydrated, no lesions
DRY
Ideal environment for ischameic wounds, No visible moisture, dressing may adhere to skin, scaly skin
Leaking
Visible free fluid, primary and secondary dressing saturated, exudate escaping onto clothes
Serous
Outpour of fluid, seen in early inflammation stages or with mild wounds
Haemoserous
Mid point of healing, surgery or tissue injury, made up of RBC's and serous fluid, pink in colour and may have red streaks
Purulent
Consists of WBC's, thick drainage, tan, yellow, green or brown, associated with infection
WOUND DIMENSIONS
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Full thickness (stage 4)
Tissue loss, visible subcutaneous fat,
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Unstageable
Full thickness tissue loss, based covered by slough and eschar in the wound bed, true depth and thickness cannot be determined
SURROUNDING SKIN
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Macerated
Softening or breaking down of skin, occurs from prolonged exposure to moisture (white looking)
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Erythema
Redness of the skin, caused by increased blood flow
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