Wound classification based on color

Wound classification based on color – instead of extent of damage to tissues

1. this system can be applied to any type of wound that is healing by secondary intention

2. surgical wounds left open due to infection can be used with this system

3. sometimes wound can have two to three colors – go by most undesireable color

4. wound colors are red, yellow, and black

Red Wound

1. characteristics – traumatic or surgical wound, and wounds created surgically to allow for healing

2. possible serosanguinous drainage: pink to bright or dark red

3. healing chronic wound with granulation tissue present ie. skin tears, stage II pressure ulcers

4. wounds that are classified as clean with reepithelializing & granulating should be kept slightly moist & free from trauma to encourage healing

5. a dressing should be used that assists the wound with epithelialization

6. dressing can be used are transparent films or adhesive semi-permeable dressings

ie. Opsite, Tegaderm allow O₂ to get to wound

9. antimicrobials can be used such as bacitracin or neomycin if infection present

10. If there is an infection the wound usually covered with sterile dressing

11. You want to avoid unnecessary handling of the tissues during dressing change. don't want to

interrupt granulation (sensitive!)

Yellow wound has the presence of slough or soft necrotic tissue, liquid to semi-liquid, slough with exudate ranges from creamy / ivory to yellow / green

1. ideal place for bacteria to grow – must be removed

2. the wound is continuously cleansed to remove exudates & soft necrotic tissue

3. the wound is continuously cleaned – use absorbent dressing to pull excess drainage from wound

4. examples of this dressing are hydrogel & foam.

5. changes depend on amount of drainage

6. when you remove dressing, you should use saline or sterile water to wash wound

7. a hydrocolloid dressing such as duoderm – can be used for yellow wounds.

8. inner of portion of dressing combine with the exudates & form hydrating gel over wound

9. when the dressing is removed then the gel stays on the wound

10. the dressing is meant to be left in place for 7 days or until leakage that occurs around dressing

Black wound – covered with thick, dried black necrotic tissue also called escar

1. examples are full-thickness burns, pressure ulcers stage III – IV, & gangrenous ulcers

2. the more necrotic tissue that is present – greater risk of infection

3. immediate treatment is debridement

   a. can be surgically.

   b. mechanical – wet to dry dressing

   c. autolytic – ie. semi-occlusive or occlusive dressing

   d. enzymatic debridement – collagenase

   e. can use negative pressure wound therapy or vac pac – this uses suction to remove drainage & promote wound healing.

   f. hyperbaric oxygen therapy delivers oxygen at different atmospheric pressure

Factors delaying wound healing

1. nutritional deficiencies: protein, vit C, CHOs, zinc

2. inadequate blood supply slows the bloods ability to carry nutrients to the wound, not carry exudates away from wound & inhibit inflammatory response

3. corticosteroids impair phagocytosis by WBCs – depress formation of granulation tissue & inhibit wound contracture

4. infection

5. mechanical friction on wound

6. advanced age – slow collagen synthesis by fibroblast, impaired circulation requires longer time for epithelialization of skin & alters phagocytic & immune responses

7. obesity – ↓blood flow due to fatty tissue

8. diabetes mellitus

9. poor general health – generalized absence of factors necessary to promote wound healing

10. anemia↓O₂ at tissue level

Complications of healing – shape, location of wound are going to affect healing ability

1. hypertrophic scars & keloid formation occur when too much collagen tissue

   a. hypertrophic scar is improperly large, red, raised, & hard

   b. it does remain to the wound edges but becomes smaller over time

2. keloids are permanent. they have a larger protrusion of scar tissue that goes beyond wound edges & forms tumor-like mass

3. contracture is necessary for wound healing. it is abnormal for excessive contracture that cause malformation or contracture of skin or muscle.

   a. usually occurs if the injury is near a joint or in burns that involve large amounts of skin damage & loss

4. dehiscence is the separation of previously (primary healing) approximated wound

   b. infection caused by inflammation

   c. granulation tissue is weak & unable to hold up to stress applied to wound

   c. obese pts have increased risk due to poor wound healing

5. Evisceration can occur with dehiscence

   a. evisceration is when organs protrude through wound

   b. if this does occur you want to put on sterile saline water with sterile gauze

6. excess granulation occurs above wound surface

7. adhesions or bands of scars around organs can develop & lead to strangulation or necrosis of surrounding tissue