Review the electronic health record. The nurse is preparing the client for discharge. After the nurse provides education about the use of a cane, which statement by the client indicates understanding?

A. Size of the wound: Measuring the wound’s length, width, and depth provides objective data on the extent of tissue damage and progress of healing. Accurate measurement during inspection helps guide treatment and evaluate outcomes.

B. Stage of wound healing: Observing characteristics such as granulation tissue, epithelialization, or necrotic tissue allows the nurse to determine the wound’s healing stage. This assessment is essential for selecting appropriate interventions and monitoring progress.

C. Continence status: While continence can influence wound development, particularly in pressure injuries, it is part of the overall client assessment, not the visual inspection of the wound itself.

D. Changes in appetite: Appetite affects nutritional status and wound healing but is not directly assessed during the wound inspection phase. This information is gathered through history rather than visual assessment.

E. Location of the wound: Documenting the anatomical location helps in planning care, preventing pressure-related complications, and monitoring for healing. Accurate location assessment is a fundamental component of wound inspection.

A. Presence of slough: Slough is yellow, white, or stringy tissue in the wound bed that represents dead or devitalized tissue. Its presence indicates impaired healing and requires debridement for the wound to progress.

B. Presence of granulation tissue: Granulation tissue is pink or red, moist, and composed of new connective tissue and capillaries. Its presence signals healthy wound healing, as it fills the wound bed and provides a foundation for epithelialization.

C. Presence of necrotic tissue: Necrotic tissue is black, brown, or gray and consists of dead cells. It impedes healing, increases infection risk, and must be removed to allow the wound to progress toward closure.

D. Presence of eschar: Eschar is a dry, leathery scab or crust that forms over a wound, usually composed of dead tissue. Like necrotic tissue, eschar must be debrided for healing to continue and does not indicate healthy tissue.