Tissue Integrity Wound Healing In Class Assignment

Hemostasis and phagocytosis are characteristic of which stage of the wound healing process? Inflammatory phase Granulation phase Maturation phase Proliferative phase

Correct! Inflammatory phase The inflammatory phase of wound healing is initiated immediately after injury and lasts 3-6 days. Two major processes occur during this phase: hemostasis and phagocytosis. The inflammatory phase is followed by the proliferative and maturation phases. There is not a granulation phase of wound healing, although formation of granulation tissue occurs during the proliferative phase.

An older adult client diagnosed with chronic obstructive pulmonary disease (COPD) is scheduled for a total knee replacement. What should the nurse include in this client's plan of care? Assess postoperative wound healing. Monitor urine output. Restrict protein intake. Expect purulent drainage.

Correct! Assess postoperative wound healing. Chronic lung disease reduces the amount of oxygen delivered to the tissues, which could delay wound healing. The nurse should assess the postoperative wound for healing. The client may or may not need to have urine output monitored. Purulent drainage is a sign of infection and would not be expected. Postoperative clients need an adequate intake of protein for wound healing; protein should not be restricted.

An older adult client with poor nutritional intake is demonstrating signs of poor wound healing. Which actions by the nurse are appropriate? Select all that apply. Assist with deep-breathing exercises. Medicate for pain prior to dressing changes. Ensure an adequate fluid intake. Encourage ambulation. Request a dietary consult for nutritional support.

Correct! Ensure an adequate fluid intake. Correct! Request a dietary consult for nutritional support. The nurse should ensure that the client receives sufficient protein and vitamins to support wound healing. The nurse should consult with a dietitian to determine ways to improve the client's intake to support wound healing. The client also needs an adequate fluid intake for wound healing. Deep-breathing exercises and ambulation may or may not help the client at this time. Medicating for pain prior to dressing changes is not going to help with wound healing.

Which of the following medications may be discontinued in a client who is experiencing delayed wound healing? Oral prednisone Oral antibiotics Topical growth factors Topical antibiotics

Correct! Oral prednisone Oral prednisone is a steroid. Steroids are known to interfere with healing, so it is likely that use of these drugs may be discontinued. In contrast, topical and oral antibiotics may be appropriate for clients with delayed wound healing, because they can help prevent infection. Topical growth factors may also be applied to a wound in an attempt to "jump start" the healing process.

A client recovering from abdominal surgery tells the nurse that "something popped" in the abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What actions by the nurse are appropriate? Select all that apply. Turn the client onto the abdomen. Position the client in bed with knees bent. Cover the area with a large, saline-soaked dressing. Notify the client's surgeon. Pack the wound with nonadherent gauze.

Correct! Position the client in bed with knees bent. Correct! Cover the area with a large, saline-soaked dressing. Correct! Notify the client's surgeon. Evisceration occurs when an abdominal wound opens and the internal viscera protrude through the incision. The nurse should cover the area with a large, saline-soaked dressing to keep the viscera moist. The nurse should also position the client with the knees bent and notify the surgeon. Nothing should be packed into this wound. The client should not be turned onto the abdomen.

A nurse working in the intensive care unit (ICU) is caring for a client who is 10 days postoperative after open abdominal surgery. The client has a well-approximated midline surgical incision that has numerous staples and a "healing ridge" noted. Which healing phase best describes the incision? Inflammatory phase Maturation phase Synthesis phase Proliferative phase

Correct! Proliferative phase The proliferative phase, the second phase in healing, extends from day 3 or 4 to about day 21 post injury. If the wound is sutured, a raised "healing ridge" appears under the intact suture line. The synthesis phase does not exist. The other choices are incorrect.

Which of the following findings suggests that a wound is infected with pyogenic bacteria? Serosanguineous exudate Purulent exudate Sanguineous exudate Serous exudat

Correct! Purulent exudate Purulent exudate is more commonly called pus, and it is created by microorganisms known as pyogenic bacteria. In contrast, sanguineous exudate consists of large amounts of red blood cells; serous exudate is clear or straw colored and has few cells; and serosanguineous exudate consists of both clear and blood-tinged drainage.

The nurse is planning care for a client with a surgical wound. Which goal is appropriate for this client? Resume independent activities of daily living. Increase ambulation. Discharge to home as soon as possible. Regain intact skin.

Correct! Regain intact skin. The client has impaired skin integrity because of a surgical wound. A goal of care would be for the client to have wound healing to achieve intact skin. Discharging the client to home may or may not be appropriate. The client may or may not be able to ambulate or perform independent activities of daily living.

A home care nurse is caring for a client who is recovering from recent surgical debridement that produced large amounts of exudate. The client's surgical wound has staples that are aiding in the wound healing. When documenting this client's care, which terminology best describes this client's care? Tertiary intention healing Primary intention healing Quaternary intention healing Secondary intention healing

Correct! Tertiary intention healing A wound that permits exudate to drain and then is closed with sutures, staples, or adhesive skin closures undergoes tertiary intention healing. Primary intention healing occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss. A wound that is extensive and involves considerable tissue loss and in which the edges cannot or should not be approximated heals by secondary intention healing. Quaternary intention healing does not exist.

The nurse is assessing a client with a surgical wound. Which observation indicates that care has been effective for this client? Erythema and edema is present. There is purulent drainage on the dressing. The client performs wound care independently. The client's temperature is 102°F.

Correct! The client performs wound care independently. Evidence of effective care for a client with a surgical wound includes the client performing wound care independently. Purulent drainage and an elevated temperature could mean the wound is infected. Erythema and edema could indicate the wound is inflamed or infected.