Visual wound guide

Epithelialising

New skin cells (epithelial cells) migrate across the wound surface creating a new, delicate layer of skin.

• Promote and protect new tissue growth.
• Consider exudate levels and apply appropriate dressing to optimise epithelialisation.

Granulating

• Presence of biofilm and alternative cleansing methods as discussed in cleansing section.
• Exudate levels and selection of dressing to optimise moisture balance. (Refer to local guidance/ formulary)

Hypergranulating (overgranulating)

• Consider any irritants at the wound bed (e.g. friction from tubing) and examine ways to manage cause.
• Consider bacterial load on the wound bed and if there is requirement for antimicrobial product.
• Refer to relevant local guidelines.
• Seek advice from appropriate healthcare professional.

Sloughy

Slough is a layer of dead tissue, which can be yellow or green in colour, and may be dry or wet on the surface.

• Consider the presence of a biofilm and the use of a surfactant solution.
• Exudate level- hydrate if dry, absorb if wet.
• Protection of skin surrounding wound if exudate levels high.
• Requirement for antimicrobial as per local guidance.

Necrotic

Necrotic tissue is a layer of dead tissue which can be brown or black in colour and is caused by inadequate blood supply or infection.

• Establish if the patient is for conservative or progressive management (see debridement section above and refer to local guidance)
• Where debridement is not indicated keep the wound environment dry.
• Where debridement is indicated, consider rehydration and use of appropriate debridement technique (as discussed in debridement section)

• Monitor for signs of infection as per local guidance.
• Consider malodour and management using appropriate dressings as per local formulary.

Undermining/tracking

A pocket or tunnelling which extends under the edge of the wound.

• Consider dressing regime to support healing.
• If packing is used, please refer to local guidance and documentation.
• Seek advice from appropriate healthcare professional.

Bone

• Maintain a moist environment to encourage new granulation tissue.
• Reduce the risk of infection.
• Seek advice from appropriate healthcare professional.

Tendon

Tendons are creamy white in colour. They will present as stringy and cord like and can move as the limb or joint flexes.

• Maintain a moist environment to prevent the tendon drying out.
• Seek advice from appropriate healthcare professional.

Haematoma

• To support appropriate and safe management refer to haematoma pathway (local or NATVNS)
• Seek advice from appropriate healthcare professional.

Erythema

• Consider emollient therapy.
• Encourage hydration through good fluid intake.
• Consider mechanical debridement of skin plaques.

Erythema

• Understand the underlying cause and treat appropriately.
• Prevent deterioration of the surrounding tissues.

• Refer to local wound infection pathways/guidance.
• Seek advice from appropriate healthcare professional.

Excoriation

• Manage moisture levels and protect the skin.
• Refer to Skin Excoriation Tool (local or NATVNS)
• Seek advice from appropriate healthcare professional.

Fragile

Skin which is friable and may appear ‘paper thin’. More vulnerable to damage.

• Protect the skin and reduce the risk of harm.
• Maintain good skin hydration.

• Consider use of full-length, soft clothing and bedding to protect skin.
• Keep nails short.
• Use approved manual handling techniques and equipment.
• Consider low adherent atraumatic dressing if appropriate.
• Consider use of adhesive removers when removing adhesive dressings and tapes.

Infection

• Confirm that the wound is infected prior to commencing treatment regime.
• Reduce bacterial load and consider the presence of a biofilm.

• Consider the use of an appropriate topical anti-microbial wound product in line with local formulary/guidance.
• Consider if systemic treatment is required in conjunction with topical products (e.g. antibiotics or antifungals)
• Use Scottish Ropper Ladder for Infected Wounds or local infection guideline/pathway for full guidance.

Oedematous

• Consider and manage the underlying cause for the oedema.
• Protect skin surrounding the wounds using barrier products.

• Manage exudate using appropriately non-adherent, absorbent products.
• Consider elevating the limb when at rest.
• Assess suitability for compression therapy (where appropriate)
• Refer to local policy/guidelines.
• Seek advice from appropriate healthcare professional.
• Consider referral to chronic oedema/ lymphoedema service if available.

Macerated

Softening and breakdown of the skin as a result of prolonged exposure to moisture (urine, sweat, wound exudate, faeces etc.)

• Consider barrier products in line with local formulary/ guidelines.
• Where appropriate, ensure correct continence products are in use.
• Refer to local pathway/guidance on moisture associated skin damage (MASD) and
• Refer to local pathway/guidance on suitably absorbent wound management products.

Haemoserous/serous (serosanguineous)

• Manage wound moisture balance utilising appropriately absorbent dressings as per local formulary/guidelines.
• Protect surrounding skin from moisture associated skin damage using appropriate barrier products in line with local formulary/ guidelines.

Haemopurulent/purulent/fibrinous

• Manage wound moisture balance utilising appropriately absorbent dressings as per local formulary/guidelines.
• Protect surrounding skin from moisture associated skin damage using appropriate barrier products in line with local formulary/guidelines.