N352 Health and Illness Tissue Integrity Definitions

Serosanguineous

clear and blood tinged

Tendon

gleaming yellow or white, shiny when healthy, strong fibrous tissue, attaches muscle to bone

Hyper granulation tissue

granulation tissue forms above the surface of the surrounding epithelium. Delays epithelialization

Pressure ulcers

have rounded, crater-like shapes with regular edges. Usually develop over a bony prominence and are therefore circular in shape, will however take on the shape of the object that caused the pressure. Deep pressure ulcers usually have a dark-red wound base and do not bleed easily. The ulcer is analogous to an iceberg; it has a small visible surface with a more extensive unknown base.

Sanguineous exudates

large amounts of red blood cells

Exudates

material such as fluid and dead phagocytic cells that has escaped from the blood vessels.

Muscle

pink to dark red, firm, highly vascular

Deep tissue injury

purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Staging of pressure ulcers

assessment system that classifies pressure ulcers based on anatomic depth of soft tissue damage. Developed by the National Pressure Ulcer Advisory Panel (NPUAP) as method of communication between health care providers. The staging system was originally developed to guide clinical description of the depth of tissue destruction that occurs with pressure ulcers. Updated in February 2007.

Granulation tissue

beefy deep pink or red, irregular surface, puffy or mounded bubbly appearance. Seen in wound bed of healing full thickness wounds. Clean non-granulating tissue - deep pink or red and smooth (non-granular) or striated (when muscle fibers are exposed)

Eschar

black brown dry non-viable( necrotic) tissue, usually darker in color, thicker, hard

Epithelial tissue

deep pink to pearly pink, light purple or lavender in color; in full-thickness wounds, new epithelial tissue migrates from the wound edges to gradually cover the granulation tissue

Necrotic tissue

defines all dead and avascular tissue

Partial Thickness

destruction of epidermis and dermis

Full Thickness

destruction of epidermis, dermis, subcutaneous and or deeper

Secondary intention healing

edges cannot or should not be approximated, involves extensive tissue loss.

Serous exudates

straw colored exudates

Purulent exudates

thick, opaque or milky appearance (pus)

Primary intention healing

tissue surfaces are well approximated and there is minimal or no tissue loss.

Tertiary intention healing

wound is left open for 3-5 days to allow edema or infection to resolve

Slough

yellow green grey, non-viable (necrotic) tissue, usually lighter in color thinner, wet stringy