The nurse notes a reddish – pink tissue in the wound during dressing and interprets as - KGMU 2024

KGMU 2024

Medical & Surgical Nursing

Easy

Appeared in: KGMU 2024

Explanation

The reddish-pink tissue described in the wound bed is granulation tissue.
This tissue is composed of new blood vessels (capillaries) and fibroblasts, which give it the characteristic red or pink color.
Its presence is a positive indicator of healthy wound healing, specifically during the proliferative phase.
The nurse should protect this new, fragile tissue to facilitate continued healing.

Option A: Signs of infection include purulent drainage (pus), foul odor, increased pain, and erythema (redness) of the surrounding skin, not the presence of healthy reddish-pink tissue within the wound itself.
Option B: A keloid is a type of raised, overgrown scar that forms after a wound has fully healed. It is not a type of tissue found within an open wound during the healing process.
Option D: Exudate is the fluid, such as blood, plasma, and cellular debris, that drains from a wound. It is not the solid tissue that forms in the wound bed.

Visual 1: Image - A chart comparing the appearance of different tissues in a wound bed: healthy granulation tissue (red/pink), slough (yellow/white), and eschar (black/brown). This helps learners visually differentiate between healthy and non-viable tissue.
Visual 2: Diagram - The four phases of wound healing (Hemostasis, Inflammation, Proliferation, Maturation), highlighting that granulation tissue forms during the Proliferation phase.

Clinical Relevance

Nursing practice connection: Knowing Wound assessment and identification of tissue types helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Accurate identification of wound tissue is a fundamental nursing skill that directly influences the plan of care, including the selection of appropriate dressings and the need for debridement.
Correctly identifying granulation tissue prompts the nurse to choose a dressing that protects this fragile new tissue and maintains a moist healing environment, thus promoting wound closure.
Misidentifying granulation tissue as infection could lead to inappropriate antimicrobial use or aggressive cleaning that damages healthy tissue and delays healing.

How to Approach the Question

First, identify the key descriptor in the question stem: 'reddish-pink tissue' found 'in the wound'.
Next, access your knowledge of wound healing. Recall the different types of tissues that can be present in a wound bed.
Associate the color 'reddish-pink' with the formation of new blood vessels (capillaries), which is a sign of new tissue growth.
Systematically evaluate each option: 'Sign of infection' involves different signs (like pus). 'Keloid' is a scar that forms after healing. 'Exudate' is fluid drainage, not solid tissue.
Conclude that 'Granulation tissue' is the correct medical term for healthy, new, reddish-pink tissue that forms during wound healing.

Concept Tested & Keywords

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