Inflammatory Phase

Question 1

Name the 8 Periwound Skin and Wound Tissue Characteristics

Answer 1

1. Periwound skin color
2. Edema and induration (hard/firm)
3. Tissue temperature
4. Pain
5. Wound tissue (bed of wound
6. Undermining/Tunneling (can happen in any phase possible infection spread)
7. Wound Edges***
8. Wound drainage (sanguinous–red; serosanguinous–colorless w/ red in it)

Question 2

Periwound Skin Color
Acute Inflammatory Phase
3

Answer 2

1. Unblanchable erythema (light-skin)
2. Discoloration or deeper color (dark skin)
3. Ecchymosis (purplish bruising)

Question 3

Periwound Skin Color
Chronic Inflammatory Phase
3

Answer 3

Halo of erythema or darkening
Hemosiderin staining (rust-brown)
Ecchymosis

Question 4

Periwound Skin Color
Absence of Inflammatory Phase
4

Answer 4

Pale or ashen skin color
Absence of erythema or absent darkening
Hemosiderin staining
Ecchymosis

Question 5

Edema and Induration
Acute Inflammatory Phase
5

Answer 5

Firmness
Taut, shiny skin
Localized edema
Consolidation (hardness) between adjacent tissues

Question 6

Edema an induration
Chronic Inflammatory Phase
3

Answer 6

Minimal firmness
Gelatinous edema seen on wound tissue
May feel boggy (mushy)

Question 7

Edema and induration

Absence of Inflammatory Phase

Answer 7

Absent

Question 8

Tissue Temperature

Acute Inflammatory Phase

Answer 8

Elevated initial temp, decreases as wound progresses

Question 9

Tissue Temperature

Chronic Inflammatory Phase

Answer 9

Minimal change or coolness

Question 10

Tissue Temperature

Absent Inflammatory Phase

Answer 10

Minimal change or coolness

Question 11

Pain

Acute Inflammatory Phase

Answer 11

Present; wound is tender and painful unless neuropathy is present.

Question 12

Pain

Chronic Inflammatory Phase

Answer 12

Minimal pain unless arterial etiology or infection, then can have intense pain

Question 13

Pain

Absent Inflammatory Phase

Answer 13

Minimal or no pain unless arterial etiology, then can have intense pain.

Question 14

Wound tissue
Acute Inflammatory Phase
5

Answer 14

Blister with clear or bloody fluid
Shallow or deep crater w/ red to pink color
Red muscle
White, shiny fascia
Yellow reticular layer of dermis with granulation buds

Question 15

Wound tissue
Chronic Inflammatory Phase
6

Answer 15

Necrotic; varies in color from yellow to brown to black.
Necrotic tissue covering full or partial surface area.
Soft or hard necrotic tissue (scab-like)
Yellow fibrin or slough (remove slough)
Part of wound has granulation tissue
Can also appear clean and pale pink.

Question 16

Wound tissue
Absent Inflammatory Phase
3

Answer 16

Covered with hard, dry eschar
Necrotic; varies in color from yellow to brown to black.
Scab

Question 17

Undermining/tunneling
Acute Inflammatory Phase
2

Answer 17

Can be present in deep wounds

Has potential for infection and abscess.

Question 18

Undermining/tunneling
Chronic Inflammatory Phase
2

Answer 18

Can be present in deep wounds

Has potential for infection and abscess

Question 19

Undermining/tunneling
Absent Inflammatory Phase
2

Answer 19

Can be present in deep wounds

Has potential for infection and abscess

Question 20

Wound edges

Acute Inflammatory Phase

Answer 20

Diffuse, Indistinct; can still be demarcating from healthy tissues (will be able to to see difference in good and bad tissue)

Question 21

Wound edges
Chronic Inflammatory Phase
2

Answer 21

Distinct; edges can be rolled or thickened

Is not continuous with wound bed if deep wound cavity

Question 22

Wound edges
Absent Inflammatory Phase
2

Answer 22

Disctinct, well-defined wound edges

Can be attached to necrotic tissue

Question 23

Wound drainage

Acute Inflammatory Phase

Answer 23

Serous or serosanguineous

Question 24

Wound drainage
Chronic Inflammatory Phase
5

Answer 24

Infection
Viscous
Malodor (bad smell)
Pus (yellow, tan, gray, or green)
Moderate to large amount

Question 25

Wound drainage

Absent Inflammatory Phase

Answer 25

Scant or dry