Assessment may begin by classification of the wound into chronic, acute and postoperative (acute wounds left to heal by primary or secondary intention) (28). Occasionally, wounds are assessed according to depth especially in USA and for pressure ulcers in the UK. The position of the wound is important as it is an indicator of potential complications e.g. mobility problems caused by wounds on the foot (28).

The MEASURE framework for wound assessment was proposed by Keast et al in 2004 (image 29) and is a simple way to assess wounds (37). Comprehensive wound assessment (wound classification, colour, depth, shape, size, exudate amount, wound location, environment of care) will influence the choice of wound dressings (37).

 

Assessment based on colours 

The pink wound is in the final stages of healing with new epithelium covering the wound. The aim is to protect this delicate tissue by providing insulation and maintaining a moist environment. The red wound is a granulating wound with new tissue filling the deficit and with some islets of epithelium present. The aim is to absorb excess exudate, maintain a moist environment and protect the wound. The yellow wound contains some slough, which is nonviable tissue that must be removed for healing to occur (37). The methods of removal are either surgical or rehydration with dressings such as hydrogels or hydrocolloids. The black wound has an outer layer of thick hard eschar, which must be removed to start the healing process. The fastest and most effective method is surgical removal. Using dressings such as hydrogels to aid autolytic debridement will be slow.

 

The green wound is often an infected wound (37). Topical antibiotics are generally discouraged. The most appropriate treatment is to control excess exudate, protect surrounding skin from toxic wound exudate, identify microorganisms and treat with systemic antibiotics. Silver dressings, cadexomer iodine and hypertonic saline dressings are beneficial for infected wounds but is insufficient alone in cellulitis or heavy infection. Critical colonisation is a transition phase between infection and colonisation, and is often well managed by antiseptic dressings (37).