3 color concept for wound assessment. intervention too

Question 1

Red

Answer 1

Red- characterized by definite borders, granulation tissue,apparent revascularization, indicates oxygenation, granulation progresses from edges to center of wound.
Interventions: maintain humidity by keeping wound covered, by doing this protects wound fluids and new cells. cleanse with sterile saline can be cleaned with running water and mild pump soap on peri wound area if DR. Approves.

Question 2

Yellow

Answer 2

Yellow: creamy to canary yellow, Oder,draining pus. Means delayed healing until infection is under control, once under control healing can start. Use sterile saline to clean.
Interventions: wash with soap and water, sterile whirlpools once infection under control, loosen necrotic tissue, wet to dry dressings. IF yellow do not proceed as an OT call DR.

Question 3

black

Answer 3

Black:wound is covered with escar-May have all phases of healing underneath,
Interventions: sterile whirlpool,work on gentle cleaning and debriding and ointments to soften.