When measuring the depth of a wound, gently insert a sterile cotton-tipped applicator into the deepest part. Measure from the tip of the applicator to skin level. Both conditions result in dead space, open areas beneath the skin that can lead to further tissue destruction and infection. When describing sinus tract formation, include the direction of the tract. Healthy tissue consists of granulation tissue, which has a red, moist, beefy appearance, and epithelialized tissue - new pink, shiny epidermis.
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.