whether the wound is acute or chronic, any presenting symptoms and the predominant tissue types present at the wound bed. The four tissue types that are commonly in wound assessment are as follows: Another important factor in wound assessment and management is to create a record of the involvement of the different skin layers within the patient’s medical records, so that any changes to the layers affected can be acted upon if necessary. Skin is made up of a number of different layers, however the three most commonly referred to are the epidermis, the dermis and the hypodermis (also known as the subcutaneous layer).
Within these layers are a network of veins, vessels and nerves, beneath which lie supporting structures made up of muscle and bone (Figure 5). page 6 1 Epithelialising tissue (Figure 1) this type of tissue provides a protective layer over the entire body. It is a series of tightly-packed cells that provide one or more layers of a natural dressing for the underlying tissues. A large amount of epithelialising tissue in a wound usually means that a wound is healing well. 2 Granulating tissue (Figure 2) this type of tissue is created when a wound is healing.
Granulating tissue is normally red or pink due to the number of tiny blood vessels present and can be quite lumpy (appearing like small buds). This type of tissue is generally healthy, and means the body is working to provide a strong, protective new layer of flesh. Some wounds however, may be described as overgranulating or hypergranulating, both of which are defined as an excess of granulating tissue, beyond the amount required for the wound to heal adequately, which can subsequently lead to infection. 3 Sloughy tissue (Figure 3) this is a mixture of dead tissue and bacteria that is separating itself from the wound site. Most sloughy tissue is white, yellow, green or grey in colour.
It is normally recommended that the tissue that is disconnected from the underlying surface is removed, before placing an appropriate dressing over the area. 4 Necrotic tissue (eschar) (Figure 4) this type of tissue is non-viable (it has no blood- supply and will not heal with time or treatment). It may be yellow, grey, purple, brown or black and can have a soft and slimy consistency or be hard and leathery. The presence of necrotic tissue can delay wound healing, and it may be necessary to surgically remove (debride) the necrosis in order to encourage healing.