Chapter 48
Which blood cells are known as garbage cells?
macrophages
According to the Braden Scale for predicting pressure ulcer risk, which factor most puts the patient at risk for developing a pressure ulcer?
poor nutrition
Which role does vitamin a play in wound healing?
promotes wound closure
What is wound dehiscence?
separation of wound edges
What ability do the dermis and inner layer of the skin provide?
tensile strength
Which support surface is useful for treating and preventing pulmonary, venous stasis, and urinary complications associated with immobility?
Kinetic therapy
What is the braden scale?
an evidence-based tool that looks at various factors that put patients at risk for developing a pressure ulcer. Includes: sensory perception moisture activity mobility nutrition friction shear
Which sign is an early indication of pressure that resolves without tissue loss if the pressure is eliminated?
blanchable erythema
Which characteristic would be indicative of abnormal healing of a primary wound?
drainage for more than 3 days after closure
In dark-skinned patients, what should the nurse keep in mind when assessing for skin changes related to the development of pressure injuries?
-blanching is not a conclusive sign in these patients -differentiate skin color changes with reference to baseline skin tone -skin temperature must also be assessed
What factors make older adults more vulnerable to developing pressure injuries?
-diminished inflammatory response -loss of collagen and thinning of muscles
What is the proliferative phase of healing?
-fibroblasts and the cells that synthesize collagen provide the matrix for granulation. -wound contracts to reduce the area that needs healing -re-epithelialization of wound surface
What is indicative of a stage 2 pressure injury?
-has a reddish-pink hue without slough
What are the other names for a bedsore?
-pressure sore -pressure ulcer -decubitus ulcer
What is the order of the 4 phases of wound healing?
1.hemostasis 2.inflammatory phase 3.proliferative phase 4. remodeling
What vitamin would be provided to a patient to promote wound healing?
A and C
What is a stage 1 pressure ulcer?
Skin intact, red, non-blanching, warm, painful
WHich stage of pressure injury can be dressed with a transparent or hydrocolloid dressing?
stage 1
What is blanchable erythema?
visible skin redness that becomes white when pressure is applied and reddens when pressure is relieved