Wound Characteristics/Appearance

Location
Body site or area on the body in which the wound is found: Pressure ulcers are generally
found over bony prominences, but may also be found in an area where localized high
pressure or shear forces was applied. It is important to accurately identify the bony
prominence. For instance, the coccyx bone is at the tip of the spinal bones, whereas, the
sacrum is the triangular shaped bone superior to the coccyx. he sacral site is a common
site of pressure ulcers and occurs in individuals who are recumbent in bed with the !"B
elevated and in individuals who sit in a reclined position either in a chair or wheel chair.
#occyx ulcers occur in individuals who sit upright in a chair. $%ote: see bony prominence
drawings&
'ower leg wounds may occur over a bony prominence or in soft tissue between bones.
'ower leg wounds may be identified in relation to body side: anterior, posterior, lateral or
medial. Pedal wounds are generally identified by foot position. For instance: plantar,
dorsal, lateral or medial aspect of the foot. Pedal wounds may also be identified bone
location. For instance: metatarsal, phalange $(
st
through )
th
digit&, calcaneus $heel& or
mallelous $an*le&.
+ounds, such as incisions, may present over the trun* of the body or a limb. In this case
the body location is identified as the anatomical position: abdominal, groin, calf, chest
etc.
,ide of the body that the wound occurs is also identified as right or left.
Size
#onsistency in terminology and measurement style is *ey in the written communication
of wound area. #entimeters is general the preferred unit of measurement. +hen
documenting the measurement, one decimal point of measurement is ade-uate. . /01
should be used if the unit of measurement is less than one centimeter, /01 point /x1 will
maintain clarity of the wound dimension. For instance: 0.2 cm. clearly reflects the
dimension is 23(0
th
centimeters, whereas, with .8 cm, the decimal point before the number
2 may be easily overloo*ed and the wound dimension interpreted as 2 cm. It is e-ually
important to place a /. 01 after the dimension if it is a one digit dimension. For instance,
2.0 cm, rather than 2 cm.
+ound dimensions include length, width and depth $if measurable depth is present&.
hese dimensions are generally measured as longest length of the open area by the
longest width of the open area by the deepest area of the wound.
4easurement of undermined areas $tunnels, cavities& further shows the extent of deeper
tissue damage. o determine the depth and extent of undermining, moisten cotton tipped
applicator with normal saline and gentle insert sideways into the wound margins at
varying intervals. +ithdraw the applicator and compare the length to a measuring guide.
5ecord the measurement and location of the undermining: right, left, superior, distal
aspect of wound. .nother method is to moisten cotton tipped applicator with normal
saline and gentle insert sideways into the wound margins at varying intervals .%6 mar*
the s*in with a waterproof mar*er at the points that the applicator meets resistance.
4easure the length by the width of the mar*ed points to determine the undermined
estimate.
he initial wound size provides information as to the healing rate of the wound. 'arger,
deeper wounds will ta*e much longer to heal than superficial shallow wounds. he size
of the wound will also help determine the fre-uency of wound measurements. +ee*ly
measurements of superficial wounds will provide needed information regarding healing
rate7 whereas, the measurements of deep cavernous wounds are not li*ely to demonstrate
appriciable change in wound dimensions in one wee*. In these wounds, the assessments
of wound tissue type will afford the clinician better insight on the wound status.
Wound Bed Tissue
he characteristic of the wound bed guides clinical decision8ma*ing in determining the
most appropriate dressing for the tissue type present. #onsideration to tissue type and
amount provides *ey information in evaluate the improvement or deterioration of the
wound. .s characteristics change, treatments are evaluated and a changed to match the
current wound characteristics.
Eschar is necrotic tissue, which appears blac* and leathery. It may have varying degrees
of adherence to the wound margin and wound bed. 9schar is dead tissue, devitalized
tissue and should not be confused with a scab. . scab is the coagulation of blood that
forms a clot that contains platelets and fibrin. ,cabs may form over partial thic*ness
wounds, such as s*in tears and abrasions.
Slough is necrotic tissue, which is in the process of li-uefying and separating from the
wound bed. he color of slough tissue may vary from yellow, tan, gray or brown tones.
he tissue generally has a gelatinous or stringy consistency.
Granulation tissue occurs during the proliferative phase of healing. :ranulation tissue is
the result of fibroplasias, the process of angiogenesis $endothelial cell migration& and
collagen synthesis. !ealthy granulation tissue appears red and fills the wound defect in
full thic*ness wounds. Partial thic*ness wounds heal by resurfacing as epithelial cells
migrate across the dermis at the wound margin and base of hair follicles. In full thic*ness
wounds epithelial cells migrate from the wound margin inward. he color and
characteristics of granulation tissue reflect the viability and health of the tissue. Pale
granulation tissue may indicate poor circulation to the wound bed, wound edema, poor
oxygenation or infection. . deep red or purple discoloration may indicate tissue damage
from excessive pressure or shearing forces. Friable granulation tissue, which bleeds
easily, may indicate infection. Protuberant granulation tissue is the development of
excessive granulation tissue and is identified as hyperplasia. !yperplasia is seen in
infected wounds and in wounds with a high pathogen bioburden.
Epithelial tissue occurs in the proliferative phase of wound healing. 9pithelial tissue
migrates across a clean healthy wound bed. he tissue appears hypo8pigmented or pin* as
it moves across the wound. "nce the wound bed is covered with epithelial tissue, the
tissue differentiates and matures forming epidermal tissue. 9pithelial tissue will not
migrate across unhealthy tissue, such as hyperplasia tissue.
Wound exudate
+ound exudate is assessed for amount, type, color and odor. 9xudate may be serous,
sero8sanguineous, sanguineous or purulent. 9xudate consists of the exuding wound fluid,
serum or blood and the by8products of topical dressings and treatments. 9xudate may be
thin or thic* and ta*e on various colors. 9xudate odor may reflect underlying infection or
be the by8product of the dressing or action of the dressing3treatment. For example,
odorous opa-ue exudate will occur in wounds undergoing chemical or autolytic
debridement. opical medications such as silver sulfamylon will produce a creamy
mucoid exudate. +ounds with critical colonization or infection may also have opa-ue
and foul drainage.
Surrounding tissue
Color of the tissue surrounding the wound is of importance in determining indications of
tissue damage or impairment in the healing process. Ideally the peri8wound color is the
color of normal s*in. 9rythema may indicate wound infection, cellulites, irritation from
wound fluid or mechanical in;ury from pressure and or shear forces. Purplish, blue8blac*
and dar* red discoloration indicate tissue trauma.
Edema may occur when inflammation is present do to infection or sustained tissue in;ury
from pressure and or shear forces. +ound site edema will also occur in the presence of
generalized edema. 9dema at the wound site impedes the healing process.
Induration is palpated and underlying tissue feels firm, hard or dense. ,ize and location
of induration is determined and monitored. Induration is an indication of wound
infection.
Pain. +ound pain is monitored for duration, intensity and causation. Pain may be
persistent or occur during wound treatments, such as wound cleansing, dressing changes
or debridement. Pain may be an indication of additional tissue trauma, infection or bone
involvement.