Registered Nurses´ Association of Ontario
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| Superficial, Increased Bacterial Burden (Critically Colonized) | Deep Wound Infection | Systemic Infection |
|---|---|---|
| Non-healing Bright red granulation tissue Friable and exuberant granulation New areas of breakdown or necrosis on the wound surface (slough) Increased exudates that may be translucent or clear before becoming purulent Foul odor |
Pain Swelling, induration Erythema Increased temperature Wound breakdown Increased size or satellite areas Undermining Probing to bone |
Fever Rigors Chills Hypotension Multiple organ failure |