The nurse is assessing the pressure ulcer of a 68-year-old female clie

The nurse is assessing the pressure ulcer of a 68-year-old female client. Which of the following would indicate to the nurse that healing is taking place?

1. Eschar
2. Slough
3. Granulation tissue
4. Exudate

ANSWER

ANS: 3
Granulation tissue is red moist tissue composed of new blood vessels, the presence of which in-dicates progression toward healing. Black or brown necrotic tissue is eschar which you will need to remove before healing can proceed. Soft, yellow or white tissue is characteristic of slough (stringy substance attached to wound bed), and you will need to remove this before the wound is able to heal. Wound exudate describes the amount, color, consistency, and odor of wound drainage and is part of the wound assessment. Excessive exudate indicates the presence of infec-tion. The presence of exudate on the skin surrounding the wound is indicative of wound deterio-ration.