5 Assessing the wound TISSUE

Epithelial Tissue

Initially appears translucent and develops into deep PINK or PEARLY color

Indicates NEW tissue growth along the wound margins and wound closure

Epithelial Islands

Patches of new epidermal tissue in the wound bed

Not attached to wound margins; often in SUPERFICIAL wounds

Bridging Epithelium

Occurs when epidermal tissue grows across the middle of the wound

Creates a bridge that separates the original wound into two areas

Usually NOT a positive sign of healing

Granulation Tissue

The growth of blood vessels and connective tissue during healing

BEEFY RED with bumpy granular appearance

Poor blood flow or infection may show pink

Non-Granulating Tissue

Appears smooth but still pink or red

Indicates viable tissue without new growth

Prompts a review of factors inhibiting tissue growth

Hypergranulation

Overproduction of granulated tissue

Shiny; appears raised, soft, spongy and extends ABOVE surrounding skin

TX: SILVER NITRATE or FOAM DRESSING (to press down)

Necrotic Tissue

Results from injury and ischemia

Indicates dead or dying tissue

Eschar

Dry, desiccated necrotic tissue

Appears BLACK or BROWN; leathery

Indicated FULL thickness

Stable Eschar

Firmly adherent to wound edges

No signs of inflammation or erythema

Acts as a natural biological cover

TX: LEAVE IN TACT; BETADINE, OTA

Unstable Eschar

Boggy or spongy feel

Has drainage and signs of infection (edema, erythema, warmth, crepitus)

Slough

Hydrated necrotic tissue

Often YELLOW or WHITE; soft, fibrinous, thin, stringy or mucinous

Indicates FULL thickness damage

Defined wound edges

Clearly demarcated- distinct, easily identifiable edges

Could easily draw out

Undefined wound edges

Difficult to identify boundary between the wound edges and peri-wound area

Attached wound edges

Surrounding skin is flush and adhered to the wound bed without any separation

Positive sign of wound healing

Unattached wound edges

Separation between the skin and the wound bed

Often indicated shearing, creates a shelf-like appearance

Fibrotic or Hyperkeratotic wound edges

Thickened skin tissue commonly found around the rim of the wound

Common with DIABETES

Callus; need to remove

Macerated or soft wound edges

Soft, wrinkly skin; soggy

Caused by excessive moisture exposure

Epibole

Occurs when the wound edges ROLL or curl under

Effectively closes off wound edges

Goal is PREVENTION; RUB and CLEAN wound edges!

Erythema

REDNESS around the wound may indicate inflammation or infection

May appear PURPLE or darker than surrounding skin in darker skin tones

Induration

Area of hardened tissue

Fluctuance

Movable, compressible, palpable fluid cavity under the skin

May indicate abscess

Crepitus

Accumulation of air or gas in the tissue

Crispy rice-cereal feeling and sound

Maceration

Caused by prolonged exposure to moisture

Leads to softening and breakdown of skin