Wound Bed Description

Question 1

hydration

Answer 1

wound should be moist enough to allow mitosis migration and synthesis by cells

Question 2

drainage

Answer 2

production/accumulation of fluid in the form of serum or pus that travels through a vessel to the adjoining tissue

Question 3

drainage type: transudate

Answer 3

water and electrolytes (sometimes called serous fluid) thin, watery-like and clean. One would see this fluid during proliferative stage of wound healing
(ie. serosanguinous - blood drainage)

Question 4

drainage type: exudate

Answer 4

consists of plasma proteins and leukocytes; it is a cloudy and viscous fluid that is marble-like in appearance.
The fluid typically exudes from deeper structures and is typically found during the inflammatory phase of healing

Question 5

drainage type: bloody (sanguineous)

Answer 5

thin or thick bright red fluid typically indicative of damage to blood vessels or granulation tissue

Question 6

drainage type: purulent (purulence)

Answer 6

thick yellow or green fluid. Dead neutrophils, bacteria and cellular debris that may be a sign of infection

Question 7

Drainage amount: none

Answer 7

dry wound environment

Question 8

drainage amount: minimal

Answer 8

tissue is moist but not excess drainage/exudates

Question 9

drainage amount: moderate

Answer 9

tissue is moist and dressing is saturated with minimal strike-through

Question 10

drainage amount: heavy/copious

Answer 10

tissue is saturated and dressing is saturated through

Question 11

odor

Answer 11

increases with bacterial burden and bacterial endotoxins

Question 12

Granulation tissue

Answer 12

formed during the proliferative phase
red/pink moist (beefy looking) tissue represents outgrowth of new capillaries and fill in an open, dead space at the start of wound healing
comprised of connective tissue, collagen, chemostatic factors, structural macromolecules, degenerative enzymes, and fibronectin

Question 13

Epithelial tissue

Answer 13

cells on the outer surface of the body that also line the cavities and tubes that lead to the exterior. During later stages of the proliferative phase, the epithelial cells migrate across a granulated wound surface.
Cells are fragile and pink in color

Question 14

Bone

Answer 14

a form of dense connective tissue comprised of osteocytes that form the human skeleton
if found in a wound bed, bone can be described as hard to the tough and off-white to light gray in color

Question 15

Slough

Answer 15

stringy, nonviable tissue in the process of separating from the viable potion of the body
usually white or yellow in color
more moist

Question 16

Eschar

Answer 16

thick, leathery, desiccated, necrotic, devitalized tissue – usually black or brown in color that may cover cavity wounds like pressure ulcers
dry

Question 17

Scab

Answer 17

a crust formed by the drying of discharge from a superficial wound

Question 18

Necrosis

Answer 18

death of tissue surrounded by healthy parts

Question 19

Dead Space

Answer 19

the cavity remaining in a wound

Question 20

Seroma

Answer 20

a collection of serum or plasma in a wound

Question 21

Sinus tract

Answer 21

a small opening in the wound bed that may lead to an abscess (tunneled into an abscess)

Question 22

Fistula

Answer 22

an opening in the wound bed that leads to a body organ or cavity

Question 23

Undermining

Answer 23

tissue erosion into the wound cavity sidewall caused by shearing forces

Question 24

Tunneling

Answer 24

an opening in the wound base that exits in the same wound or an adjacent wound

Question 25

Shape - neuropathic wound

Answer 25

typically round in shape over sites of bony prominences and weight/bearing surfaces during ambulation

Question 26

Shape - arterial insufficiency wounds

Answer 26

typically “punched out” in shape and are located on the ties, feet and distal third of the lower extremities

Question 27

Shape - venous insufficiency wound

Answer 27

irregular in shape and typically located on the medial aspect of the lower extremity proximal to the malleoli

Question 28

Location - arterial insufficiency

Answer 28

typically located on the toes or disal third of the lower extremity but can be found anywhere depending on where the blockage of arterial flow has occurred

Question 29

location - venous insufficiency

Answer 29

found above or below the medial malleolus but could be circumferential at the ankle depending on the location of the traume

Question 30

location - neuropathic wounds

Answer 30

found over the plantar aspect of the foot with diminished or absent protective sensation.