Generally, if a wound looks "good", it means there is no evidence of infection or dehiscence (gaping open) and that it is healing. There are several ways of describing them:
- for stapled or sutured wounds: Staples are intact, with some erythema that is a reaction to the staples/sutures. Wound looks good with no drainage.
- Drainage from a wound is bad...you should describe it in terms of "serous" (clear fluid that is not viscous...kind of like urine)..."sanguinous" (bloody but again not viscous)...or "serosanguinous" (mixture of above 2, which is usually the case). "Purulent drainage" describes yellow, thick fluid that is pus.
Now sometimes there is an abscess in there that only comes out when you squeeze the wound...you can describe this as "Purulent drainage expressed from wound". Typically this is referred to as a wound that has "pussed out".
If there is redness that looks like cellulitis, you just describe it as erythema...like "Wound is healed, with no open areas, but there is surrounding erythema measuring about 5 x 10 cm".
The keys to describing a wound are the following:
- is the wound closed? In other words, are there any areas along the wound that are open?...it could be a "less than 1 cm area at superior/middle/inferior aspect of wound that is open but not draining".
- Are the sutures/staples in or out. If there is some tissue reaction to the staples that does not look like an infection, you might as well leave this out of your description. Use the word "erythema" only if you're concerned it could be an infection.
- Is there drainage from the wound? Describe the drainage and whether it is draining freely or whether you had to express it. Either way, if it's pus, it's pus and doesn't matter if you expressed it or not.
- Are the wound edges well-approximated? If not, is the wound "dehisced"? How much of it? You can say: "The middle 3 cm of the wound has dehisced but the wound edges along the remainder of the wound are well-approximated".
- For wounds that have been left to close by secondary intention: is there "healthy granulation tissue in the wound bed"? Or is there "fibrinous material within the wound bed"...fibrinous material is kind of yellowish but is NOT pus...students often confuse this yellow stuff with pus. The fibrinous material usually needs to be debrided so you get down to healthy granulation tissue that bleeds.
Healthy granulation tissue is beefy and red and bleeds if you mess with it.
The skin surrounding the wound should also be described: the skin can be "necrotic/nonviable" or "viable/clean". Necrotic skin needs to be excised because it won't heal.
As far as VACs are concerned...you can describe it like this: Wound is covered with a VAC sponge, and secured with Ioban, creating an air-tight vacuum seal. The VAC suction device is functioning. This may be too much detail...Most of the time, just saying that "The VAC is on and functioning" is enough...
As far as dressings: if the dressing is covered in blood, say "the dressing is saturated"...you can also say "the dressing is mildly or moderately saturated". Otherwise, dressing is described as "clean and dry".
You should be able to describe any wound problems with the above. Hope this helps.
