wound healing

Question 1

what are the four phases of wound healing

Answer 1

-hemostasis
-inflammatory
-proliferative
-maturation

Question 2

describe hemostasis

Answer 2

-first phase (occurs within 48 hours after wound)
-vasoconstriction
-exudate producation
-platelet activation -> clot formation

Question 3

desrcibe the inflammatory phase

Answer 3

-vasodilation (increases drainage)
-phagocytosis (wound is flooded with WBCs)
-localized inflammatory response (looks like infection with redness, warmth, swelling, and tenderness)
-lasts 4-6 days

Question 4

describe proliferative phase

Answer 4

-rebuilding, new tissue fills wound space
-lasts 3-24 days
-fibroblasts ad growth factor create collagen and blood vessels
-granulation tissue formation (not always visible, thin layer, super vascular)

Question 5

describe maturation phase

Answer 5

-can take up to two years
-collagen matures
-scar tissue is created (less elastic and string than surrounding tissue, avascular with no hair or sweat)

Question 6

in which phase of the wound healing process is new tissue built to fill the wound space, primarily through the action of fibroblasts?

Answer 6

proliferation phase

Question 7

name some different types of wound healing

Answer 7

-primary intention (primary union)
-secondary intention (contraction and epithelialization)
-tertiary intention (delayed closure)

Question 8

describe primary intention (primary union)

Answer 8

-clean incision
-minimal tissue loss
-early suture
-“hairline” or minimal scarring

Question 9

describe secondary intention (contraction and epithelialization)

Answer 9

-gaping irregular wound
-heals from the bottom up
-epithelium grows over scar
-scarring and infection are more prevalent
-examples may include pressure injuries, deep lacerations, or burns

Question 10

describe tertiary intention (delayed closure)

Answer 10

-wound is intentially left open for a period of time
-may be unable to close or need to monitor for bleeding

Question 11

name some systemic factors that affect wound healing

Answer 11

-age (old ppl take long to heal)
-nutrition (protein, vitamins A & C, zinc)
-circulation and oxygenation
-health status (diabetes, shock, immunosupression, obesity, chemotherapy, steroids, antibiotics)

Question 12

name some local factors that affect wound healing

Answer 12

-moisture (desiccation or maceration)
-trauma **
-edema** (interferes with blood flow)
-infection (increased stress to the body and demand of resources)
-bleeding (clots may need to be evacuated)
-necrosis (no healing with dead tissue)
-biofilm (thick collection of bacteria, can make wound difficult to treat)

Question 13

what is desiccation

Answer 13

drying, dehydrated, crust

Question 14

what is maceration

Answer 14

excessive moisture

Question 15

name some complications of wound healing

Answer 15

-hemorrhage or hematoma
-dehiscence or evisceration
-infection
-fistula

Question 16

describe hemorrhage

Answer 16

-can see
-low Hgb and Hct

Question 17

describe hematoma

Answer 17

-collection of blood under intact skin, warm to touch, painful
-form in dependent area
-low Hgb and Hct

Question 18

describe dehiscence

Answer 18

-wound edges separate
-r/t infection or wound stress

Question 19

describe evisceration

Answer 19

-emergency
-abdominal organs escaping

Question 20

describe infection

Answer 20

-occurs 7 dyas after wound
-microorganisms get in there
-sepsis and ostomyolitis

Question 21

describe fistula

Answer 21

abnormal connection between two adjacent organs/vessels that usually do not connect

Question 22

what are 5 signs of localized infection

Answer 22

1. redness
2. heat
3. edema
4. pain
5. altered function

Question 23

what wound complication is cuased by over hydration related to urinary and fecal incontinence

Answer 23

maceration

Question 24

what subjective data is included in assessment of skin integrity

Answer 24

-normal skin condition
-hx of skin conditions/wounds
-psychosocial effects of impaired skin integrity (pain, fear, anxiety, impact of ADLs, change in body image)

Question 25

what objective data is included in the assessment of skin integrity

Answer 25

-visual, tactile, olfactory assessment (wound assessment, presence of tubes or devices, areas of pressure) -nutritional status -risk scoring tools -diagnostic tests (ex. biopsy)

Question 26

what are some findings of intact skin

Answer 26

-color -temperature -moisture -texture -odor -turgor

Question 27

what are some examples of nurses diagnoses r/t skin integrity

Answer 27

-impaired skin integrity -impaired tissue integrity -risk for infection -imblanced nutrition -pain

Question 28

describe outcome identification and planning r/t skin integrity

Answer 28

-patient speicifc and patient focused -ex. skin will show no signs of breakdown during hospitalization

Question 29

describe implementation r/t skin integrity

Answer 29

-**health promotion** (sunscreen, skin checks) -**prevention of pressure injuries** (positionaing and skin care, pressure recucing surfaces) -**pateint teaching** (hygiene and handwashing, pressure injury prevention, symptoms of infection) -**prevent and manage wounds** (remove nonviable tissue and manage wound exudate) -**protect wounds** (dressing) -**monitor lab values** -**provide nutritional support** -**teach patient appropriate wound care**

Question 30

describe evaluation r/t skin integrity

Answer 30

-evaluate pt outcomes r.t goals of the care plan -evaluate and revise interventions

Question 31

look at this

Answer 31

Question 32

the use of sharp tools to remove devitalized tissue is called...

Answer 32

surgical debridement

Question 33

assessing a wound on a foot, the nurse finds tissue destruction down to the bone. what would the nurse classify this as?

Answer 33

stage 4 pressure injury

Question 34

which statement best describe the healing process for a surgical wound that was closed with sutures? A. debridement aids in the surgical healing process B. new tissue fills sides and base of wound C. the proliferative stage is longer with surgical wounds D. the edges of the wound are approximated

Answer 34

D