Use Case(s)

A clinician wishes to document colors within the base of a wound.

Artifact

Wound bed color refset

Purpose of Refset

The purpose of this refset is to document the colors within the base of the wound. The mobile app "Tissue Analytics" color and texture to determine color. They store "red" to represent granulation, "yellow" to represent slough and "black" to represent necrosis. VA nurses want to have additional colors such as "purple" which may indicate infection by a specific organism.

Examples of what to include

The value set only includes colors that may exist in a wound bed/base.

Examples of what to exclude

Odor, consistency

Zero or one OR Zero or more

There can be more than one color documented.

Editorial Guidelines

Considerations for editing wound bed color (http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Wound_care/) 

• Granulating: healthy red tissue which is deposited during the repair process, presents as pinkish/red coloured moist tissue and comprises of newly formed collagen, elastin and capillary networks. The tissue is well vascularised and bleeds easily
• Epithelializing: process by which the wound surface is covered by new epithelium, this begins when the wound has filled with granulation tissue. The tissue is pink, almost white, and only occurs on top of healthy granulation tissue
• Sloughy: the presence of devitalized yellowish tissue. Is formed by an accumulation of dead cells. Must not be confused with pus
• Necrotic: wound containing dead tissue. It may appear hard dry and black. Dead connective tissue may appear grey. The presence of dead tissue in a wound prevents healing
• Hypergranulating; granulation tissue grows above the wound margin. This occurs when the proliferative phase of healing is prolonged usually as a result of bacterial imbalance or irritant forces

Similar Refsets

Not applicable.

Associated Clinical Quality Measures

<Identify if this refset will be associated with any clinical quality measures>