What type of tissue is found in a pressure injury?
Understanding the depth and type of the tissue in the wound bed is extremely important for skilled nursing nurses. Documentation of the tissue type is required for completion of the long-term care Resident Assessment Instrument and Minimum Data Set 3.0.
If the wound bed is covered with eschar or slough, the pressure injury must be documented as unstageable. If it is only partially covered and the depth of the wound can be palpated and visualized, the tissue in the wound bed should be assessed and staged.
In order to identify the type of tissue in a wound bed, nurses treating wounds require training and competency evaluation. If there is a question about the tissue type, the nurse assessing the wound bed should consult with a colleague.
According to the MDS 3.0, these are the four tissue types that could be noted in the pressure injury wound bed:
1. Epithelial tissue: This is new tissue growth. It usually appears light pink and shiny. In a Stage 2 pressure injury, it can be visualized at the wound edges or can arise from hair follicles in the wound bed. In full-thickness (Stages 3 and 4) wounds, it will appear only at the wound edges.
2. Granulation tissue: This is a replacement scar tissue that fills in the tissue deficit. It is moist, red tissue that has a bumpy or cobblestone appearance and bleeds easily.
3. Slough tissue: This is a yellow or tan, stringy, non-viable tissue that may adhere to the wound bed.
4. Eschar: This is soft or hard devitalized tissue that is black, brown or tan. It usually adheres to the wound bed.
Nurses must have a complete understanding of the tissue in the wound bed, competency training, and correct documentation.
Please send your wound treatment-related questions to “Ask the Expert” at [email protected].
From the July 03, 2017 Issue of McKnight's Long-Term Care News
