Warrington Division

CLASSIFICATION AND MANAGEMENT OF WOUNDS

Necrotic Sloughy Malodorous/ Infected Granulating Epithelialisation AIMS OF TREATMENT

Debride Remove slough

Absorb Exudate Maintain moisture Maintain MoistureRemove eschar Absorb Exudate Treat infection Promote granulation and protect Protect wound Provide clean base Manage Smell Provide healthy base

for granulation tissue Protect wound for Epithelialisation

Protect wound Protect wound

TREATMENT CHOICES

Hydrogels Low Exudate Low Exudate Low Exudate Hydrogels

Hydrocolloids Hydrogels Antimicrobial Creams Hydrogels Films

Films Hydrocolloids Low absorbent foams Hydrocolloids Low absorbent foams

Desloughing Agents* Low absorbent foams Silver impregnated Low absorbent foams Non adherent foams

Enzymes Desloughing Agents dressings Non adherent foams

Surgical Debridements High Exudate High Exudate High Exudate

Hydrofibre Hydrofibres Hydrofibres

Alginates Foams Alginates Alginates

Dextranomer agents Bordered foam dressings Bordered foam dressings

Warrington Division

WOUND CLASSIFICATION

Classification is an important tool which will enhance assessment of the wound, direct the planning of the treatment and facilitate evaluation of the wound at a later stage.

Grade 1 Discolouration of intact skin, including non blanchable, erythema, blue purple and black discolouration

Grade 2 Partial thickness skin loss or damage involving the epidermis and or dermis

Full thickness skin loss involving damage or necrosis of subcutaneous tissues but not through the underlying fascia Grade 3 and not extending to the underlying bone, tendon or joint capsule

Full thickness skin loss with extensive destruction and tissue necrosis loss extending to the underlying bone, tendon Grade 4 or joint capsule

In order to enhance classification it is also possible to identify wounds in terms of their appearance:

Wound Type Wound Appearance Wound Colour

Type N Necrotic area of dead tissue Black

Type S Slough, dead cells in exudate Yellow

Type M/I Malodorous and or infected Green

Type G Granulating Tissue Red

Type E Epithelialisation Pink