types of exudates + wound terminology

specon

Serous

Clear straw-colored

Serous, Fibrinous, Serosanguinous, Sanguinous

Thin watery (4)

Serous, Fibrinous

Significance: Normal (2)

Fibrinous

Cloudy

Fibrinous

May indicate fibrin strands present.

Serosanguinous

Opaque / pink

Serosanguinous

Significance: May indicate the presence of red blood cells and capillary damage from, e.g. traumatic dressing removal or surgery

Sanguinous

Red

Sanguinous

Significance: May indicate trauma to blood vessels.

Sanguinous

Significance: May indicate low protein content d/t malnutrition

Sanguinous

Significance: Venous or congestive cardiac failure.

Sanguinous

Significance: May indicate presence of fistula

Seropurulent

Murky yellow / cream / coffee

Seropurulent

Thicker / sticky / creamy

Seropurulent

Significance: May indicate a bacterial infection and/ presence of necrotic liquid / tissue

Purulent

Yellow / grey / green

Purulent, Hemorrhagic

Thicky / sticky

Purulent

Significance: May indicate infection.

Purulent

Significance: Contains pyogenic (pus generating) organisms and other inflammatory cells

Purulent

Significance: Consequent damage to dermal capillaries leads to blood leakage

Haemopurulent

Dark, blood-stained

Haemopurulent

Viscous / stick

Haemopurulent

Significance: Will indicate an infection and will contain neutrophils, dead/dying bacteria and inflammatory cells.

Haemopurulent

Significance: Consequent damage to dermal capillaries leads to blood leakage.

Hemorrhagic

Dark red

Hemorrhagic

Significance: Indicates infection and/ trauma.

Hemorrhagic

Significance: Capillaries are so friable they readily break down and spontaneous bleeding occurs.

Hemorrhagic

Significance: Not to be confused with bloody exudate produced by over-enthusiastic debridement.

wound base

Bottom of the wound (deepest)

wound depth

Vertical distance from the visible surface to the deepest area

wound depth

The distance from the top layer of the periwound area to the deepest layer of the wound

wound edges / margins

aka Periwound Area

wound edges / margins

normal skin around the wound

wound edges / marguns

Inside the perimeter of the wound

macerated

This is when skin is exposed to moisture for a prolonged period of time

epibole

rolled edge

epibole

Wound edge is curled under/inwards, preventing wound closure

callused wound

Fibrotic, hyper-keratotic, an excess in production of skin

periwound area

Skin surrounding the wound

4 cm

periwound area has a minimum of

erythema (red)

color of periwound area when there’s infection, trauma, inflammation

white

color of periwound area when there’s moisture (maceration)

blue / purple cyanotic

color of periwound area when there’s poor blood flow, trauma

denuded

Loss of epidermis, caused by exposure to urine,
feces, body fluids, wound exudate or friction

erosion

loss of epidermis

Excoriated

linear erosion

Excoriated

destruction of skin by mechanical means (stretch)

tunneling

Channel or pathway that extends in any direction from the wound through the subcutaneous tissue

undermining

Tissue destruction underlying intact skin along the wound margins

undermining

caused by shearing forces

necrotic tissue

Non-viable, dead tissue

slough

type of necrotic tissue that is yellow, greek grey

slough

type of necrotic tissue that is lighter, thin, wet

slough

type of necrotic tissue that is stingy

slough

type of necrotic tissue that is by -product of infection

eschar

type of necrotic tissue that is black, brown grey

eschar

type of necrotic tissue that is darker, thicker

eschar

type of necrotic tissue that is hard

eschar

type of necrotic tissue that is shell like on top of wound

epithelial tissue

outermost layer of skin

epithelial tissue

deep pink to pearly pink

epithelial tissue

closure of the wound, healing

granulation tissue

new tissue that replaces dead tissue

granulation tissue

beefy, red color

granulation tissue

puffy and mounded

granulation tissue

grows from the base of the wound

hyperganulation tissue

forms above the surface of the wound

hyperganulation tissue

delays epithelialization

muscle tissue

pink to dark red

muscle tissue

highly vascularized

muscle tissue

striated, grooved, or ridged

muscle tissue

usual striations

tendon

attaches muscle to bone

tendon

shiny when healthy

tendon, fascia

shiny and white

fascia

hypodermal area

fascia

covering over the muscles

fascia

great organizer

bony

shiny and smooth

wound base color

dictates if wound is healing properly

beefy red

color if tissue is healthy and has good blood flow

pale pink

color if there is poor blood flow, anemia

purple

color if there is engorned, swelling, high baterial levels, trauma

black/brown

color if there is non-viable, necrotic tissue

yellow

color if there is non-viable tissue, slough

green

color if there is non-viable tissue, active infection

white

color if it is macerated, poor blood flow