TIME mneomnic for assessment of wounds
Tissue: presence of granulation or hypergranulation tissue, devitalized or necrotic tissue, and surrounding tissue
Inflammation or infection: areas within or surrounding the wound site that may indicate the presence of infection or inflammation
Moisture: moisture balance and whether the wound is dry or macerated
Edge of the wound: assess for re-epithelialization vs non-advancing ages vs epibole. Also assess blood supply to the edges of the wound.
Parts of a wound
| Part | Definition | Description |
|---|---|---|
| Marging | A line that represents the junction between instact skin and the ulcer | Rounded or oval. Regular or Irregular. Well-defined or ill-defined. |
| Edge | The block of tissue that connects the margin and the floor of the ulcer | Sloping, undermined, punched out, raised and beaded, or everted |
| Floor | Visible part overlying the base | Contanins discharge, granulation tissue (red/pink) or slough (yellow) |
| Base | Tissue on which the ulcer rests on | Bone, tendons, or muscle |
Size
Wound size should be measured and documented on first presentation and regularly after that. Dimensions include length, width and depth of tissue planes. Wounds can be measured using a tape, ruler, scalpel handle or gloved finger.
Margin
| Margin | Inference |
|---|---|
| Ill-defined irregular margins | Growing or spreading ulcer |
| Well-defined regular white margin | Non-healing ulcer |
| Well-defined regular margin with white, blue, and red zones | Healing ulcer |
| Nodules on margin | Rodent ulcer (BCC) |
Edges
| Edges | Inference |
|---|---|
| Sloping edge | Healing ulcer, venous ulcer |
| Punched out edges | Aretrial and Gummatus ulcer |
| Raised and everted edges | Malignancy |
| Undermined edges | Tuberculous ulcer, Amoebic ulcer in the intestines |
| Raised non-everted edges | Basal cell carcinoma |
Epibole: a rolled or curled-under wound edge where the epithelial layer fails to advance. The upper epidermal edge moves over the lower edge causing epithelialization down the wound edge rather than across the base. They must be resected or debrided in order for epithelialization to continue.
Floor
| Floor content | Inference |
|---|---|
| Pink with tiny red granules or nodules (capillary “buds”) | Healthy granulation |
| Pale flat granulation, “heaped up” appearance | Unhealthy granulation, exuberant granulation |
| Scanty serous discharge | Can be seen in healthy granulation |
| Yellow, white, or grey slough | Infection has not been controlled and granulation is yet to begin |
| Serosanguinous purulent discharge | Infected ulcer |
| Dry, hard, or leathery, and black | Eschar |
Surrounding skin
Inspect the surrounding skin for cellulitis, maceration, and other peri-wound skin abnormalities e.g. scars, deformities, rashes, and varicosities.
