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 secondary intention wound

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

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

• Do not apply moisture to ischemic areas
• Full assessment of individual should be considered ie vascular assessment
• Consider hydroactive dressings /hydrogel/hydrocolloid
• Medically prepared honey
• Sharp debridement only by competent healthcare professional

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 or colonisation/infection present
• Hydrofibre if exudate moderate to high
• Larvae
• Sharp debridement only by competent healthcare professional

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

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 

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 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 if no active bleeding present

• Hydrogel/Hydroactive dressing
• Hydrofibre
• Alginate
• Seek advice from appropriate healthcare professional

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

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 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
• Apply super-absorbent dressings for very high exudates

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
• Consider antimicrobial dressings product
• Levels of exudate will determine dressing type ie hydrofibre/foam dressing for high exudate

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 absorbent dressing
• Consider barrier preparation in line with local policy/guidelines

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

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

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

Skin which appears ‘paper thin’ and dry.

Protect surrounding skin

• Consider emollient therapy
• Consider low adherent atraumatic dressing if appropriate

Scaly skin which appears hard and dry.

Promote moisture

• Consider emollient therapy
• Consider low adherent atraumatic dressing if appropriate

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 or
• Iodine based dressing or
• 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