Healthy granulation tissue is beefy red and moist; pale or dusky tissue suggests poor perfusion.
Before you read
Test yourself first: 5 questions
Question 1 of 5
A nurse plans to apply a transparent film dressing. For which wound is a transparent film dressing MOST appropriate?
Answer: B. Transparent film dressings (such as Tegaderm) are semipermeable, allow visualization of the wound, and are best for superficial wounds with little or no exudate, including Stage 1 injuries, partial-thickness wounds, or to secure IV sites. They are not appropriate for heavily exudating or infected wounds because they cannot absorb drainage.
Question 2 of 5
A nurse is selecting a dressing for a Stage 3 pressure injury that has moderate exudate and needs a moist wound environment to promote granulation. Which dressing property is most appropriate?
Answer: A. Modern wound care promotes a moist (not wet or dry) wound bed to support granulation and epithelialization. For a Stage 3 wound with moderate exudate, a dressing that absorbs excess drainage while keeping the bed moist, such as a hydrocolloid or foam dressing, is appropriate. Drying the wound out with frequent open-air exposure or harsh antiseptics impairs healing.
Question 3 of 5
A nurse cares for a deep wound with heavy exudate. Which dressing is most appropriate because of its high absorptive capacity?
Answer: B. Calcium alginate dressings are derived from seaweed and are highly absorbent, making them ideal for wounds with heavy exudate; they form a gel that supports a moist environment. Hydrocolloid and transparent film dressings are not appropriate for heavily draining wounds.
Question 4 of 5
A nurse is preparing to perform a sterile wet-to-moist dressing change on an abdominal wound. Which action reflects correct sterile technique during the procedure?
Answer: B. During a sterile dressing change, the nurse performs hand hygiene, dons clean gloves to remove the soiled dressing, removes those gloves, performs hand hygiene again, and dons sterile gloves before handling sterile supplies and the wound. The sterile field and items at or above waist level are kept within view and not turned away from.
Question 5 of 5
A nurse is cleansing a clean granulating pressure ulcer at routine dressing changes. Which solution is preferred for cleansing this type of wound?
Answer: B. Normal saline (0.9 percent sodium chloride) is the preferred cleanser for clean, granulating wounds because it is isotonic and noncytotoxic, preserving healthy granulation tissue. Povidone-iodine, hydrogen peroxide, and full-strength antiseptics are cytotoxic to fibroblasts and impair healing.
Keep the streak going with more questions like these, each with a full rationale.
What is wound care?
Wounds heal by primary intention (clean, surgically closed edges), secondary intention (open wound healing from the base up by granulation), or tertiary intention (delayed closure). Choosing the right moist wound environment and recognizing infection early are central nursing skills. Nutrition, perfusion, and glucose control strongly influence healing.
Key points to remember
- Healthy granulation tissue is beefy red and moist; pale or dusky tissue suggests poor perfusion.
- Wound healing phases are hemostasis, inflammation, proliferation (granulation), and maturation/remodeling.
- Serous drainage is clear/watery, serosanguineous is pink, sanguineous is bright red, and purulent is thick and colored, indicating infection.
- A moist wound bed heals faster than a dry one; appropriate dressings maintain moisture balance.
- Wound dehiscence is partial or complete separation of wound edges; evisceration is protrusion of organs through the opening.
- Diabetes, smoking, steroids, infection, and poor nutrition delay healing.
Nursing priorities
- Assess wound size, depth, tissue type, drainage, periwound skin, and odor at each dressing change.
- Clean wounds from least to most contaminated (center outward) using sterile normal saline and aseptic technique.
- Select dressings appropriately: hydrocolloid/hydrogel for dry wounds, alginate/foam for heavy exudate.
- Obtain wound cultures before starting antibiotics when infection is suspected.
- For evisceration, cover protruding tissue with sterile saline-soaked gauze, keep the patient NPO, and notify the surgeon immediately.
Labs & values
Patient teaching
- Wash hands before and after dressing changes and follow the demonstrated sterile or clean technique at home.
- Eat protein, vitamin C, and zinc-rich foods and keep blood sugar controlled to speed healing.
- Report increasing redness, swelling, warmth, foul drainage, fever, or wound separation.
Red flags: report now
- Sudden gush of serosanguineous drainage or a 'popping' sensation suggests dehiscence; have the patient lie still and assess.
- Evisceration is a surgical emergency; cover with moist sterile gauze, position low-Fowler with knees flexed, and call the provider.
- Increasing pain, spreading erythema, fever, or purulent foul drainage signals infection; escalate.
- Never push protruding organs back into the wound.
References
Clinical references for this topic
