Wound Bed Description Flashcards
hydration
wound should be moist enough to allow mitosis migration and synthesis by cells
drainage
production/accumulation of fluid in the form of serum or pus that travels through a vessel to the adjoining tissue
drainage type: transudate
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)
drainage type: exudate
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
drainage type: bloody (sanguineous)
thin or thick bright red fluid typically indicative of damage to blood vessels or granulation tissue
drainage type: purulent (purulence)
thick yellow or green fluid. Dead neutrophils, bacteria and cellular debris that may be a sign of infection
Drainage amount: none
dry wound environment
drainage amount: minimal
tissue is moist but not excess drainage/exudates
drainage amount: moderate
tissue is moist and dressing is saturated with minimal strike-through
drainage amount: heavy/copious
tissue is saturated and dressing is saturated through
odor
increases with bacterial burden and bacterial endotoxins
Granulation tissue
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
Epithelial tissue
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
Bone
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
Slough
stringy, nonviable tissue in the process of separating from the viable potion of the body
usually white or yellow in color
more moist
Eschar
thick, leathery, desiccated, necrotic, devitalized tissue – usually black or brown in color that may cover cavity wounds like pressure ulcers
dry
Scab
a crust formed by the drying of discharge from a superficial wound
Necrosis
death of tissue surrounded by healthy parts
Dead Space
the cavity remaining in a wound
Seroma
a collection of serum or plasma in a wound
Sinus tract
a small opening in the wound bed that may lead to an abscess (tunneled into an abscess)
Fistula
an opening in the wound bed that leads to a body organ or cavity
Undermining
tissue erosion into the wound cavity sidewall caused by shearing forces
Tunneling
an opening in the wound base that exits in the same wound or an adjacent wound
