It is crucial to note the length, width and depth of the wound in centimeters, in addition to whether the wound is tunneling or undermining. Look for signs of infection such as redness, pain and drainage. Check for necrotic and granulation tissue. Necrotic tissues are characterized by reddish brown fragmentation and form thick and leathery black eschar (dead tissue). Oftentimes, this masks an underlying collection of pus or an abscess. Meanwhile, healthy granulation tissues appear as shiny, uneven or bumpy, beefy red at the wound base.
Also document the type of tissue using the 0 to 4 scale rating: 0 for a closed or resurfaced wound, 1 for superficial epithelial tissue, 2 for granulation tissue, 3 for slough tissues characterized by yellow to white tissues with mucous and 4 as a necrotic tissue. Get the sum and place it on a graph to monitor any changes or progress in the condition of the wound.
Remove the soiled wound dressing and dispose of it properly. Dress the wound with fresh gauze.
Keep in mind that the length may not be the longest measurement here. Sometimes, the width may be longer than the length depending on the clock position.
Remove the applicator and hold it against the ruler to measure the depth of the wound margin based on the mark seen on the applicator stick. Then, estimate the amount of wound granulation in congruence to the percentage of the wound surface. Be sure to document your assessment findings properly.
At this point, the body sends white blood cells - particularly the neutrophils and macrophages - to the site of the wound to kill bacteria and promote wound healing. The inflammatory phase usually lasts around 2 to 4 days from the time of wound injury.
Healthy granulation tissue should not easily bleed and will appear pinkish or reddish in color. Dark granulation tissue indicates poor tissue perfusion or insufficient oxygen and nutrient levels. It may also indicate ischemia or infection. [8] X Research source Ischemia is characterized by a bluish discoloration around the wound which indicates poor tissue perfusion. It occurs when the blood flow to the capillaries or small vascular beds and blood vessels is impeded. Wound healing sets in when homeostasis between the collagen synthesis and breakdown is achieved.
During the maturation phase, remodeling or replacement of Type III collagen with Type I collagen takes place until such a time that the collagen tissue almost equates to the texture of normal skin and mimics approximately 80% of uninjured tissue.
