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Source:

Nursing2015

May 2007, Volume 37 Number 5 , p 26 - 27

Author

  • CONNIE M. SARVIS RN, CON(C), CWD, IIWCC, MN, FCCWS

Abstract

SUPPOSE YOUR 74-year-old patient has an open wound that won't heal (see photo), although you've followed best practice wound care guidelines. The wound hasn't changed size in 3 weeks, is bright red, and has increasing amounts of exudate. You also notice yellowish-brown slough in the right lateral aspect and a slightly sweet odor that you hadn't noticed before. This is the time to call on NERDS to help determine if the wound is critically colonized. But before we discuss the NERDS assessment tool, let's evaluate what's happening in this wound.

What's a critically colonized wound?

A critically colonized wound lacks clinical signs of infection, despite supporting a bacteria level close to the maximum level the host can tolerate.

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