Wounds are classified by the color
of the wound bed. Wound color helps the physicians or the wound care
"team" determine whether debridement is appropriate.
Patients need to be picky about
the color of the wound color. Only
RED
will do, and the best shad is
"blood Red"
- not
"pale pink"
or
"grayish red".
There are thousands of words to describe colors; however, you can simplify your
assessment by sticking to the
"RED-YELLOW-BLACK" Classification System.
Red 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.
If the wound bed is
yellow, patients need to take caution. Yellow is the color of exudate
produced by micro-organisms in an open wound. A yellow color in the wound
bed may be a film of fibrin on the tissue. Fibrin is a sticky substance
that normally acts as a glue in tissue rebuilding. However, if the wound
is unhealthy or too dry, fibrin builds up into a layer that can't be rinsed off
and my require debridement. This exudate appears whitish yellow, creamy
yellow, yellowish green, or beige. The fibrin or water content influences
shade. Tissue that has recently died due to ischemia or infection may also
be yellow and need to be debrided.
Black is the
least healthy color, and this is a direct signal towards necrosis or tissue
death. Dead, vascular tissue slows healing and provides a site for
micro-organisms to proliferate. Debridement is always necessary for a
black wound. After removing dead tissue, the surgeon will make sure that
wound is guarded against external contamination. Enzyme products, surgical
debridement, hydrotherapy with whirlpool or high pressure irrigation is commonly
used to help necrosis healing.
Sometimes the wound exhibits more than one color, and can have up to three
colors in a wound. Classify the wound according to the least healthy color
present. If the wound is red and yellow, the wound would be classified as
a yellow wound.
