A nurse is assessing a chronic pressure ulcer on a bedridden patient. Which finding would indicate that the wound is progressing normally through the proliferative phase of healing?
1Presence of bright red bleeding and clot formation
2Wound edges that are widely separated with purulent drainage
3Thick, dry scab covering the entire wound surface
4Pink, granular tissue filling the wound bed with new capillary formation✓ 정답
해설
The proliferative phase (days 3-21) is characterized by pink, granular granulation tissue with new capillary formation. Other options describe inflammatory phase or abnormal findings.
Core Nursing ExplanationKey Concept Analysis: This question tests your understanding of the normal stages of wound healing, specifically the Proliferative phase. Wound healing follows a predictable sequence: Hemostasis, Inflammatory, Proliferative, and Maturation (Remodeling). The proliferative phase is when the body actively rebuilds the wound bed with new tissue and blood vessels. For a chronic Pressure ulcer, recognizing normal progression versus infection or delayed healing is a critical nursing assessment skill.
Answer Rationale: Key Point! The hallmark of the proliferative phase is the formation of Granulation tissue. This tissue is pink or red, moist, and has a granular, "bumpy" appearance because it is rich in new, fragile capillaries (angiogenesis). This tissue fills the wound bed from the bottom up, providing a foundation for epithelial cells to migrate across. Therefore, option ④ perfectly describes this normal, healthy finding.
Distractor Analysis:
Option ① (Presence of bright red bleeding and clot formation): This describes the immediate Hemostasis phase and the early Inflammatory phase (days 1-3). While some bleeding is normal initially, bright red bleeding in a chronic wound is a sign of trauma to fragile granulation tissue, not normal progression.
Option ② (Wound edges that are widely separated with purulent drainage): This indicates Watch out for confusion!Wound infection or Dehiscence (separation of wound layers). Purulent (pus) drainage is a classic sign of infection, not normal healing. Widely separated edges suggest poor healing or increased tension.
Option ③ (Thick, dry scab covering the entire wound surface): A dry scab (eschar) is necrotic tissue. In moist wound healing theory, a dry environment can impede epithelial cell migration and trap bacteria underneath. For a pressure ulcer, eschar often needs to be debrided to allow the proliferative phase to proceed.
Related Concepts: Understanding wound bed characteristics is essential for choosing the correct wound dressing (e.g., hydrogel for dry wounds, absorptive dressings for exudative wounds). The NPUAP Pressure Injury Staging System (now from the NPIAP) classifies tissue loss depth, but healing is assessed by the phases described here.
Protect fragile tissue; use moist dressings; assess for healthy pink tissue.
Maturation
Week 3 - 2 years
Collagen remodeling, scar strengthening, fading.
Support scar with moisturizers/silicone; protect from sun.
Side-by-Side Comparison!
Finding
Indicates...
Action
Pink, moist, granular tissue
Normal Proliferative Phase
Continue plan; use non-adherent, moist dressing.
Yellow Slough (stringy, moist)
Necrotic tissue / Devitalized tissue
Autolytic, enzymatic, or mechanical Debridement may be needed.
Black Eschar (hard, dry)
Necrotic tissue / Full-thickness damage
Surgical/sharp debridement often required for healing.
Purulent Drainage (thick, colored)
Infection (e.g., Pseudomonas = green-blue)
Obtain culture; administer antibiotics; increase frequency of dressing changes.
Anatomy, Physiology & Pharmacology Points
Physiology: Granulation tissue is primarily composed of Fibroblasts (produce collagen) and new capillary loops. The pink color comes from oxygenated blood in these capillaries.
Pharmacology: Nutritional support is key. Vitamin C is essential for collagen synthesis. Zinc supports epithelialization. Protein intake must be adequate to provide building blocks for tissue repair.
Memory Tips
Proliferative = Pink & Prolific: Think of the "P"s. The phase is Proliferative, and the tissue is Pink and Prolific with new growth.
From Assessment to Intervention: "The nurse observes pink, granular tissue in a pressure ulcer. Which dressing is most appropriate?" (Answer: A non-adherent, moist dressing like a hydrocolloid or foam).
Identifying Abnormal Findings: "Which finding requires immediate notification to the provider?" (Answer: Purulent drainage with foul odor and fever).
Nutritional Focus: "A patient with a Stage III pressure ulcer has poor dietary intake. The nurse should encourage foods rich in which nutrient to support wound healing?" (Answer: Protein and Vitamin C).
Nursing Clinical Practice GuideClinical Scenario: You are caring for Mr. Johnson, an 82-year-old man with advanced dementia who is bedridden. He has a Stage III pressure ulcer on his sacrum. During your shift assessment, you remove the hydrocolloid dressing.
Nursing Intervention Strategy:
Assessment: Perform wound assessment using the TIME framework:
Tissue: Is it viable (pink granulation), non-viable (yellow slough/black eschar), or infected?
Infection/Inflammation: Check for redness, warmth, swelling, pain, purulent drainage, odor.
Moisture Balance: Is the wound too dry (needs hydration) or too wet (needs absorption)?
Edges: Are they attached, rolled under (epiboly), or macerated?
For Mr. Johnson, you note pink, granular tissue filling 60% of the wound bed—a positive sign of the proliferative phase.
Care & Dressing Selection: Since the wound is in the proliferative phase with healthy granulation tissue, your goal is to protect it. Choose a dressing that maintains a moist environment, protects from shear/friction, and doesn't damage the tissue upon removal (e.g., hydrocolloid, foam, or non-adherent silicone dressing).
Patient Safety & Precautions:
Turn & Reposition every 2 hours to keep pressure off the ulcer site. Use pillows for off-loading.
Use a pressure-redistributing mattress.
Keep the skin around the wound clean and dry to prevent Watch out for confusion!Maceration (softening/breakdown from moisture).
Monitor for signs of infection: Increased pain, fever, change in drainage color/odor, worsening erythema.
Nursing Procedure & Medication Flow
Wound Cleansing: Use normal saline or a wound cleanser. Avoid harsh antiseptics like hydrogen peroxide or povidone-iodine on granulation tissue, as they can damage new cells.
Dressing Change: Use sterile technique if the wound is deep or tunneling. For a clean, granulating wound, clean technique may be sufficient per facility policy. Always follow standard precautions (gloves).
Nutritional Support: Collaborate with the dietitian. Ensure adequate intake of protein (1.2-1.5 g/kg/day), vitamin C, and zinc. Consider nutritional supplements if oral intake is poor.
Pain Management: Administer analgesics (e.g., acetaminophen) before dressing changes if the procedure is painful.
A Word from Your Senior Nurse
"Remember, your eyes and hands are your best assessment tools. That pink, beefy-looking tissue in a wound? That's a sign your patient's body is fighting hard to heal. Celebrate it! But never get complacent. A wound that was pink yesterday but is pale or dusky today is telling you something is wrong—maybe poor perfusion or infection. Wound care is a dynamic process. On the NCLEX, they love to test if you can distinguish between what's normal in healing and what's a red flag. In clinicals and on the exam, always link your assessment finding to the phase of healing and let that guide your next nursing action."
Proliferative Phase — The stage of wound healing (days 3-21) characterized by the formation of granulation tissue, angiogenesis, and epithelialization.
Granulation Tissue — Pink/red, moist, granular tissue composed of fibroblasts and new capillaries that fills the wound bed during the proliferative phase.
Pressure Ulcer — Localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.
Debridement — The removal of non-viable tissue (slough or eschar) from a wound to promote healing.
Angiogenesis — The physiological process of forming new blood vessels, which is essential for delivering oxygen and nutrients to granulation tissue.