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Size and Depth

Wounds not classified with staging or grading can be described based on the
depth of tissue damage. The descriptions used for depth of burn injury,
superficial, partial, and full thickness, can also be used to describe depth in
other types of wounds.. A calibrated grid, photographs, tracings, graphs, and
specifically designed forms are most commonly used to document wound size
and depth.
Wound Area/ measurement and Volume Assessment
 Assessments are performed weekly or biweekly to document the
effectiveness of therapy, make changes in treatment if necessary, and
support the overall treatment plan.
 Linear measurements of length (maximum length measured in the axis
from head to toe), width (maximum width perpendicular to the length),
and depth are commonly used in clinical practice. (typically in
Drainage is measured by observation and is often described in terms of color
and thickness. Examination of wound drainage may be very important because
it may indicate a normal response to trauma (few days) or a prolonged response
to necrotic tissue, a foreign substance in the wound, or infection.

Wound Appearance
 To describe wound appearance, the red–yellow–black system is often
 One method is to classify a wound as the least advantageous of the three
colors that it displays.
 The color of the wound surface can be alternatively described as a
relative percentage of the three colors.
 Digital photography makes it convenient to serially classify with wound
 Normal physiological wound healing is a complex, dynamic process that
can be defined as comprising four main phases: hemostasis,
inflammation, proliferation, and tissue remodeling.
 Immediately following injury, the healing response begins with the
activation of the coagulation cascade and the creation of a blood clot,
producing hemostasis and preventing further blood loss.
 Inflammation is characterized by breakdown nof the preexisting tissue
scaffolding and cleanup of
extracellular and pathogen debris.
 Acute inflammation lasts only minutes to days depending on the extent of
injury as leukocytes, predominately neutrophils, invade the wound and
clear it of debris.
 Granulation tissue formed during the proliferative phase of healing
provides a temporary weak tissue layer in the wound.
 Granulation tissue is so called because of the pink, soft granular surface
 Collagen is constantly being synthesized and degraded in order to gain
strength through the reorientation of collagen fibers, as wound tissue
approaches full strength.
 Collagen deposition in normal wound healing reaches a maximum by 21
days after the wound is created; however, it may take up to 2 years or
more for a scar to completely form.
Common sites for