During a dressing change, inspection of the wound reveals what appears to be reddish pink tissue in the wound. The nurse interprets this as?

Appeared in: AIIMS Rishikesh & Jodhpur NO - 2017

Explanation

The description of 'reddish pink tissue' in a wound bed is the classic presentation of granulation tissue.
Granulation tissue is composed of new capillaries, fibroblasts, and inflammatory cells, which are essential components of the proliferative (healing) phase of a wound.
The rich blood supply from the newly formed capillaries is what gives this healthy tissue its characteristic reddish-pink color.
Its presence is a positive indicator that the wound is healing correctly and is not a sign of complication.

Option A: Exudate refers to the fluid or drainage that comes from a wound. It is not solid tissue. While wounds have exudate, the 'reddish pink tissue' itself is not exudate.
Option C: Eschar is necrotic (dead) tissue. It is typically black or brown, hard, and leathery, which is the opposite of the 'reddish pink' description.
Option D: Granulation tissue is a sign of healthy healing, not infection. Signs of infection include purulent (pus-like) drainage, foul odor, increased pain, warmth, and erythema (redness) of the skin surrounding the wound.

Clinical Relevance

Nursing practice connection: Knowing Wound assessment and identification of tissue types during wound healing helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Accurate wound assessment is a fundamental nursing responsibility that directly impacts patient outcomes. Correctly identifying tissue types guides the selection of appropriate dressings and interventions.
Nurses must meticulously document the wound's appearance, including the type, amount, and color of tissue and any exudate, at each dressing change to track healing progress or identify complications early.
What if? - If the tissue observed was yellow and stringy instead of reddish-pink, the nurse would interpret this as slough. This indicates non-viable tissue that needs to be removed (debrided) for the wound to heal, and the plan of care would need to be adjusted accordingly.

How to Approach the Question

First, identify the key descriptive phrase in the question stem: 'reddish pink tissue in the wound'.
Next, access your knowledge of the wound healing process and the different types of tissue that can be present in a wound bed.
Systematically evaluate each option against the description. 'Exudate' is fluid, not tissue. 'Eschar' is black/brown, not pink/red. 'A sign of infection' involves other signs like pus, not healthy tissue growth.
Match the description 'reddish pink tissue' to its correct definition, which is granulation tissue, a sign of healthy healing.
Confirm your choice by recalling that the color comes from new blood vessel formation, which is a hallmark of the proliferative phase of healing.

Concept Tested & Keywords

Concept Tested: Wound assessment and identification of tissue types during wound healing.
Stem keywords: dressing change, wound, reddish pink tissue
Lead-in keywords: interprets this as

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E6 Pathology-Vandana Puri & Kavita Gaur Textbook of Pathology and Genetics pp. 92-94, 95-97

Practise the full AIIMS Rishikesh & Jodhpur NO - 2017

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