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Wound Bed
Assessment of the wound bed includes observing and recording the tissue types, levels of exudate and the presence or absence of local and/or systemic wound infection. A wound will consist of different tissue types at different stages of healing. These tissue types are often described by colour – Black, Yellow, Red and Pink and tools such as the “Wound Healing Continuum” (Gray et al., 2010) have been developed. This tool incorporates intermediate colour combinations between the four key colours. This practical approach to everyday wound care enables the practitioner to approach wound assessment logically and systematically.
Wound Healing Continuum (derived from Gray et al., 2010)
It must be noted that this approach has been criticised for being too simplistic, as wound healing is a continuum, and wounds often contain a mixture of tissue types. The wound healing continuum is an effective audit tool and an aid to clinical judgement making, it does not replace sound clinical judgement (Gray et al., 2010). However, it is still useful to be able to identify the four main types of tissue found during wound healing whilst recognising, and giving consideration to the possibility that more than one tissue type will coexist in a wound as it heals.
To decide upon the correct care and management of a wound and appropriate dressing selection, it is necessary to identify the tissue type. A wound may have a variety of these tissues present at any one time.
The tissue type within the wound will determine the primary aim of treatment (see Module 4). The percentage of tissue types present in a wound should be recorded during the initial assessment. Any changes in the percentages can act as a marker of wound improvement or deterioration (Eagle, 2009).