Necrotic tissue is avascular and is described as either slough or eschar tissue. Slough appears in an array of yellow, grey, green, and brown colors. Eschar is a hard, black, leathery tissue. Assess the exudate for volume, color, consistency, and odor. Volume of exudate is described as scant, small, moderate, or copious, and includes the number of dressings soaked with drainage.
Consistent documentation allows nurses to monitor trends in wound drainage.
Odor, color, and consistency of exudate can alert the nurse to the presence or absence of wound infection. The condition of periwound skin, the area surrounding the wound opening, provides further information concerning the patient's health status, the efficacy of a dressing's absorption of exudate, and the presence of local infection. The nurse needs to observe this area for erythema, induration, crepitus, hematoma formation, maceration, desiccation, denudation, blistering, and pustule formation. New tissue growth at the lesion's margins supports epithelial migration and contraction of the wound. A moist wound environment is essential.