Definitions of Terminology used on Wound Assessment Chart
Types of Tissue at Wound Bed
Necrotic - Dead tissue, hard, black/brown in colour
Slough - Dead tissue/wound debris may be adherent or loose, yellow/white in colour
Granulation - New tissue and capillary "buds" that fill the wound, red/deep pink moist with a "bumpy" appearance
Overgranulation - granulation tissue which grows above the level of the surrounding skin, preventing epithelial cells from growing across the wound
Epithelialisation - new skin cells growing across the wound, pink/white in colour at the wound edges or in islands over the granulation tissue.
Condition of Surrounding Skin
Macerated - softening and breakdown of skin from prolonged exposure to moisture presents as moist, red/white, wrinkled
Oedematous - abnormal collection of fluid in the tissue, skin is swollen, shiny and tense
Eczematous - Acute or chronic inflammation of the skin presenting as redness, irritation, weeping, crusting or scaly areas.
Dry - dehydration of the skin presenting as flaky, scaly or thick skin plaques.
Fragile - unbroken skin which appears thin, delicate and liable to be damaged.
Erythema - redness of the skin caused by congestion of capillaries in lower layers of the skin, may be due to injury, infection or inflammation.
Cellulitis - Inflammation of the tissues presenting as oedema, redness, pain and heat often with hardness of the tissues and a demarcation of the red area
Blisters - collection of fluid under the epithelial layer, fluid may be clear or pink/red in colour.
Intact - No obvious breaks in the skin surface
Healthy - Normal skin with no breaks and none of the above problems
Exudate
Serous - clear fluid which leaks out through cell membranes and blood vessels, straw coloured
Haemoserous - blood stained fluid when serous fluid mixes with blood, red/pink in colour
Purulent - frank pus is coming from the wound indicating infection, yellow/green in colour, may be brown/red if infection is causing wound to bleed.