Visual Guide | Right Decisions

Tracking/undermining

A tunnelling effect or pocket under the edge of the wound.

Extension of the wound bed into adjacent tissue, also known as a sinus tract.

Aid healing from inside wound

Loose packing/layering with alginate/hydrofibre
or hydrogel
Seek advice from appropriate healthcare professional

Necrotic soft/hard

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. It may be soft or hard on the surface, can be of varying depth and may produce an offensive smell.

Rehydrate and remove sloughy/necrotic tissue

Aid healing from inside wound

Do not apply moisture to ischemic areas
Full assessment of individual should be considered ie vascular assessment
Consider alginogels /hydrogel/hydrocolloid
Medically prepared honey
Sharp debridement only by competent 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. It can be of varying depth and may produce an offensive smell.

Remove all debris

Hydrogel if exudate low
Medically prepared honey if exudate low
Hydrofibre if exudate moderate to high
Larvae
Sharp debridement only by competent healthcare professional

Granulating

The development of new tissue from the wound base which typically appears bright red in colour, and has a rough or irregular surface.

To encourage granulation tissue

Hydrocolloid if exudate low to moderate
Non-adherent dressing if exudate low to moderate
Hydrofibre if exudate moderate to high
Non-adherent dressing with pad/foam dressing if exudate moderate to high

Epithelialising

Healing of the surface layer of the skin where delicate new skin cells eventually appear at the edges or middle of the wound as tiny pink specks.

Protect and promote new tissue growth

Hydrocolloid if exudate low to moderate
Non-adherent dressing with pad/foam dressing if exudate moderate to high

Hypergranulating

Also known as overgranulating.
An overgrowth of granulating tissue which appears ‘proud’ of the wound, preventing epthelisation.

Lessen inflammatory response

Refer to local guidelines
Seek advice from appropriate healthcare professional

Haematoma

Haematoma is a collection of congealed blood from a leaking blood vessel which appears like a blood filled blister.

Reduce devitalised tissue and blood clot from wound bed

Hydrogel
Hydrofibre
Alginate
Seek advice from appropriate healthcare professional

Bone

Bone is a whitish hard mass that is rigid when palpated.

Maintain a moist environment

Hydrogel and non-adherent dressing
Seek advice from appropriate healthcare professional

Tendon

Tendons are whitish and tough but flex when palpated.

Maintain a moist environment

Hydrogel and non-adherent dressing
Seek advice from appropriate healthcare professional

Haemoserous

Haemoserous is thin and watery fluid which is blood tinged in appearance.

Serous is thin and watery fluid which is pale yellow in appearance.

Manage wound moisture balance

Non-adherent dressing if exudate low
Non-adherent dressing with pad/foam dressing
if exudate moderate to high

Purulent

Thicker fluid containing pus which may vary in colour from yellow to green.

Reduce infection and exudate

Look for other signs of infection (see Infection)
Assess level of exudate
Levels of exudate will determine dressing type
ie hydrofibre/foam dressing for high exudate

Macerated

Maceration of the skin occurs when it is wet for a prolonged period of time. The skin softens and wrinkles and will appear white or grey. The skin can easily become infected with bacteria or fungi.

Reduce excess moisture level

Hydrofibre dressing
Highly absobent dressing
Consider barrier preparation in line with local policy/guidelines

Oedematous

Swollen area of skin due to retention of fluid.

Manage exudate

Non-adherent highly absorbent dressing.
Refer to local policy/guidelines
Seek advice from appropriate healthcare professional

Erythema

Abnormal redness of the skin resulting from enlarged blood vessels under the skin.

Protect surrounding skin

Determine underlying cause
If appropriate, protect fragile tissue with
non- adherent dressing

Excoriation

Excoriated skin can be caused by excessive moisture and can vary in colour from pink to red.

Manage moisture to protect skin

Use a suitable barrier product and follow manufacturers instructions for correct application.
Refer to Skin Excoriation Tool or local guidelines
If severe seek advice from appropriate healthcare professional
Use of correct foam cleanser or skin wipes
(ph 5.5)
Gentle drying of area

Fragile

Skin which appears ‘paper thin’ and dry.

Protect surrounding skin

Consider emollient therapy
Consider low adherent atraumatic dressing
if appropriate

Dry/Scaly

Scaly skin which appears hard and dry.

Promote moisture

Consider emollient therapy
Consider low adherent atraumatic dressing
if appropriate

Infection

Common signs and symptoms of an infection may include increased pain, spreading erythema, increased exudate level, foul odour, friable tissue and slough.

Reduce bacterial load

It is important to confirm if the wound is infected, identify the cause and determine whether antibiotics are required
Medically prepared honey
Iodine based dressing
Silver dressing
Use Algorithm for Assessment and Management
of Chronic Wounds
Use Scottish Ropper Ladder for Infected Wounds
Use of PHMB products for cleansing
Use of antimicrobial alginogels for dressing