The nurse is monitoring a patient's stage 3 pressure ulcer for healing during treatment. Which finding indicates that the nursing interventions have been effective?
a. The wound has a grainy, spongy texture.
b. There is a hard crust over the wound.
c. The wound drainage is serosanguinous.
d. The patient states that pain is minimal.
ANS: A
Granulation tissue is a sign of healing and has a budding appearance, from the development of tiny new capillaries. If the granulations are healthy, they have a slightly spongy texture. A hard crust indicates eschar, which must be removed for healing to occur. Serosanguinous drainage indicates absence of infection, not healing. Minimal pain is a good outcome but is not a measure of healing.
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