Saturday, 23 October 2010

TAILORING WOUND CARE TO WOUND COLOR

Promote healing in any wound by keeping it moist, clean, and free of debris. For open wounds, use wound color to guide the specific management approach and to assess how well the wound is healing.
Red wounds
Red, the color of healthy granulation tissue, indicates normal healing. When a wound begins to heal, a layer of pale pink granulation tissue covers the wound bed. As this layer thickens, it becomes beefy red. Cover a red wound, keep it moist and clean, and protect it from trauma. Use a transparent dressing (such as Tegaderm or Op-site), a hydrocolloidal dressing (such as DuoDerm), or a gauze dressing moistened with sterile normal saline solution or impregnated with petroleum jelly or an antibiotic.
Yellow wounds
Yellow is the color of exudate produced by microorganisms in an open wound. When a wound heals without complications, the immune system removes microorganisms. However, if there are too many microorganisms to remove, exudate accumulates and becomes visible. Exudate usually appears whitish yellow, creamy yellow, yellowish green, or beige. Dry exudate appears darker.
If your patient has a yellow wound, clean it and remove exudate, using irrigation; then cover it with a moist dressing. Use absorptive products (for example, Debrisan beads and paste) or a moist gauze dressing with or without an antibiotic. You may also use hydrotherapy with whirlpool or high-pressure irrigation.
Black wounds
Black, the least healthy color, signals necrosis. Dead, avascular tissue slows healing and provides a site for microorganisms to proliferate.
You should debride a black wound. After removing dead tissue, apply a dressing to keep the wound moist and guard against external contamination. As ordered, use enzyme products, surgical debridement, hydrotherapy with whirlpool or irrigation, or a moist gauze dressing.
Multicolored wounds
You may note two or even all three colors in a wound. In this case, classify the wound according to the least healthy color present. For example, if your patient's wound is both red and yellow, classify it as a yellow wound.