How to assess ‘the gap’
In this section, you’ll learn:
Inadequate wound assessments can lead to inappropriate treatment choices, poor patient outcomes and additional resource cost.1 Knowing what to look for when examining the wound – and the gap between the wound bed and the dressing – will give you a clearer sense of the condition of the wound and help you to decide how to create an optimal healing environment.
The Triangle of Wound Assessment is an important tool here. You can use it on all wound types, and it guides you in how to conduct a thorough assessment of the gap between the wound bed and the dressing. You can read more about the Triangle of Wound Assessment here.
What to look for when assessing the gap
Beforewe look into the actual assessment process, it’s important to remember that effective wound management goes beyond the wound itself.
When caring for a patient with wounds – chronic or non-chronic – it's always important to take a holistic approach. That means taking note of the patient’s overall medical history and health as well as the condition of the wound itself. If you need to refresh your knowledge of holistic wound management, visit the section here.
In a thorough assessment of the wound – and the gap between the wound and the dressing – you should consider:2
- how long has the patient had this wound?
- what is the wound’s aetiology (i.e. what caused it)?
- how is it healing? Do you see any signs of progress?
- what are the wound’s characteristics?
- Here you should look at:
- the wound’s depth, undermining, tunnelling and fistulas
- the underlying wound bed structure and topography
- the tissue quality. Are there signs of granulation or necrosis?
- the periwound (surrounding) skin and the wound edge
- the exudate, or fluid in the wound – its colour, consistency, odour and amount
- Here you should look at:
If you notice that exudate is pooling, or if you believe that the exudate’s composition is preventing the wound from healing, your first priority should be to remove the excess exudate. Choosing the right wound dressing is the best way to do this. You can read more about how to do that here.
How often should I assess the gap?
Youshould complete a full assessment of a patient’s chronic wound at least once a week or, if possible, every time you change the dressing. This will help you diagnose and treat any wound infection in the early stages. By detecting an infection early on, you reduce the risk of serious complications, such as limb- or life-threatening infections.2
As you assess the wound, look for the following warning signs:
- exudate pooling, leakage and soiling1, 3
- periwound skin damage (for example, maceration, skin stripping or erosion)
- delayed wound healing3
- signs of infection
- frequent dressing changes
Find out more about how to manage the gap here.
Exudate: The different types and colours
The following chart describes the different types of exudate. The wound’s exudate gives you important information about the wound’s health. If you notice an unexpected change in exudate characteristics, this may mean that there is a change in the wound’s status, e.g that the wound is infected. If this happens, you should re-evaluate the wound as quickly as possible.4, 3
Type: Serous
Colour: Clear, amber or straw-coloured
Consistency: Thin, watery
Type: Serosanguineous
Colour: Clear, pink to light red
Consistency: Thin, slightly thicker than water
Type: Sanguineous
Colour: Red
Consistency: Thin, watery
Type: Seropurulent
Colour: Cloudy, creamy, yellow, tan
Consistency: Thin
Type: Fibrinous
Colour: cloudy
Consistency: Thin, watery
Type: Purulent
Colour: opaque, milky, yellow, tan or brown, sometimes green
Consistency: Often thick
Type: Haemopurulent
Colour: reddish milky, opaque
Consistency: Thick
Type: Haemopurulent
Colour: Red, opaque
Consistency: Thick
References
- Triangle in Practice (2019) Wound International
- Keast, David H. et al. Managing the gap to promote healing in chronic wounds – an international consensus. Wounds International 2020. Vol 11, issue 3
- World Union of Wound Healing Societies (WUWHS) Consensus Document. Wound exudate: effective assessment and management. Wounds International, 2019
- Adderly, U.J (2010) Managing wound exudate and promoting healing
You may also be interested in…
HEAL e-learning
Learn about holistic and systematic wound assessment and management with this EWMA-endorsed course.
Patient case
Learn how a macerated venous leg ulcer was managed with a silicone foam dressing.
Triangle of Wound Assessment
Conduct a holistic and systematic wound assessment with our tool.