Chapter 11 Inflammation and Healing

The nurse is caring for a patient with a pressure ulcer who has a 20-year history of smoking. Which education does the nurse give regarding wound healing and smoking? 1 It impedes blood flow to healing areas. 2 It slows collagen synthesis by fibroblasts. 3 It decreases the blood supply in fatty tissue. 4 It decreases the supply of nutrients to the injured area.

1 Cigarettes contain nicotine, which is a potent vasoconstrictor, and thus impedes blood flow to healing areas and delays wound healing. A decreased blood supply in fatty tissue is a consequence of obesity. Advanced age may result in slow collagen synthesis by fibroblasts. A decreased supply of nutrients to the injured area occurs due to inadequate blood supply.

The nurse is caring for a patient four days after an open abdominal surgery. The nurse assesses that the edges of the incision are approximated. When documenting the patient's wound, which term does the nurse use to indicate this phase in primary intention healing? 1 Initial 2 Maturation 3 Granulation 4 Scar contraction

1 During the initial phase of primary intention, there is an approximation of incision edges, a migration of epithelial cells, and the appearance of clots that serve as a meshwork for starting capillary growth; therefore the nurse should use this term when documenting the appearance of the wound. The duration of this phase is three to five days. Granulation occurs when there is a migration of fibroblasts, secretion of collagen, abundance of capillary buds, and the wound is fragile. Maturation and scar contraction occur when there is a remodeling of collagen and strengthening of the scar.

The nurse is educating a patient and family members about pressure ulcers. Which is the priority nursing action when conducting the educational session? 1 Demonstrating correct positioning to prevent skin breakdown 2 Emphasizing the importance of proper nutrition for wound healing 3 Teaching the patient and family how to inspect the patient's skin daily 4 Assessing the patient and family's financial resources for wound care

1 Patient and caregiver education regarding pressure ulcers begins with prevention; therefore the nurse's first priority is to teach the patient and family the correct positioning for preventing the occurrence of skin breakdown. Next, the nurse should assess the patient and family's skill levels in conducting wound care, along with their financial resources to do so. The nurse should then teach the patient and family to inspect the skin each day. Finally, the nurse should educate the patient and family about the importance of proper nutrition as it pertains to wound healing.

The nurse is caring for a patient who has an infected postoperative abdominal wound that is open and being treated with wet-to-dry sterile saline dressings. How does the nurse anticipate healing to occur? 1 Tertiary intention 2 Primary intention 3 Secondary intention 4 Remodeling of tissues

1 Tertiary intention healing occurs with delayed suturing of a wound in which two layers of granulation tissue are sutured together. This occurs when a contaminated wound is left open and sutured closed after the infection is controlled. It also occurs when a primary wound becomes infected, is opened, is allowed to granulate, and is then sutured. Tertiary intention usually results in a larger and deeper scar than primary or secondary intention. Primary intention healing takes place when wound margins are approximated neatly, as in a surgical incision or a paper cut. A continuum of processes is associated with primary healing. These processes include three phases (initial phase, granulation phase, maturation phase) and scar contraction. The process of healing by secondary intention is essentially the same as healing by primary intention. The major differences are the greater defect and the gaping wound edges. Healing and granulation take place from the edges inward and from the bottom of the wound upward until the defect is filled. There is more granulation tissue, and the result is a much larger scar. Remodeling of tissues is an incorrect response.

An unlicensed assistive personnel (UAP) informs the registered nurse (RN) about a reddened area on a patient's coccyx. The RN instructs the UAP to perform which follow-up action? 1 Reposition every hour. 2 Measure the size of the reddened area. 3 Massage the area to increase blood flow. 4 Evaluate the area in four hours.

1 The most important thing to do for this patient is to prevent deterioration of the ulcer and eliminate factors that lead to pressure ulcers. This would include eliminating pressure on the reddened area by repositioning the patient every hour. The RN must complete the assessment of the new reddened area as well as evaluation of the area; these tasks cannot be delegated. Massage is not used when there is the possibility of damaged blood vessels or fragile skin, so the RN should not include this intervention until further assessments are made.

The nurse is educating a patient with a wound that has been difficult to heal and who is scheduled for hyperbaric oxygen therapy. The patient asks, "How will this treatment help?" How does the nurse respond? Select all that apply. Correct1 "It kills anaerobic bacteria." 2 "It prevents formation of new blood vessels." 3 "It slows down formation of granulation tissue." Correct4 "It increases the effectiveness of certain antibiotics." Correct5 "It increases the killing power of white blood cells (WBCs)."

1, 4, 5 Hyperbaric oxygen therapy involves delivering oxygen at increased atmospheric pressure. The therapy kills anaerobic bacteria in the wound, preventing further infection. It increases the killing power of WBCs and certain antibiotics. The therapy also promotes angiogenesis (growth of new blood vessels) to facilitate wound healing. Hyperbaric oxygen therapy accelerates formation of granulation tissue, which in turn accelerates the wound healing process.

Which type of primary dressing would the nurse select for a patient whose wound has moderate-to-heavy exudate? Select all that apply. 1 Foam dressing 2 Alginate dressing 3 Non-adherent dressing 4 Hydrogel dressing 5 Gauze dressing

1,2 Foam dressings and alginate dressings are best suited for moderate-to-heavy drainage or exudates. These dressings provide protection from infection and also can hold large amounts of exudates. Non-adherent dressings are used for minor wounds or as a secondary (cover) dressing. Hydrogel dressings are used for dry wounds. Gauze and nonwoven dressings are used for maintaining a moist wound surface or are used as secondary dressings; they are not used as the primary dressing for a heavily exudative wound and are not suitable for wounds that have drainage or exudates.

The nurse is caring for a patient who has a deep wound. To determine the organism and the most effective antibiotic, a culture and sensitivity test is prescribed. Which techniques does the nurse use to obtain the specimen? Select all that apply. 1 Extracting wound fluid from deep tissue layers 2 Rotating a culture swab over a cleansed 1 cm area near the center of the wound 3 Taking a culture of the necrotic tissue 4 Aspirating a tissue sample using a small-gauge needle 5 Sending the sample to the laboratory within four hours

1,2 The nurse can obtain cultures using the swab technique. This is done using Levine's technique, which involves rotating a culture swab over a cleansed 1-cm area near the center of the wound. Enough pressure should be applied to extract wound fluid from deep tissue layers. The culture should be taken of the clean tissue because exudate and necrotic tissue will not provide an accurate sample. Health care providers perform needle and tissue punch biopsies. The sample must be sent to the laboratory within one hour.

In which order will the nurse perform care when treating a pressure injury? 1.Assess for risk factors. 2.Plan a treatment for the injury. 3.Implement wound care. 4.Evaluate wound treatment.

1,2,3,4 The nursing process begins with assessment. The nurse will first assess for risk factors requiring treatment to prevent further injury. Next, care is planned for treatment of the injury. Planning is followed by implementation of the planned care. Finally, treatment is evaluated for effectiveness and desired outcomes.

The registered nurse provides education for a group of nursing students related to assessing for pressure ulcers on patients with dark skin. Which information does the nurse include? Select all that apply. Correct1 "Look for changes in skin color, such as skin that is darker (purplish, brownish, bluish) than surrounding skin." 2 "Use a fluorescent light source to accurately assess the skin color." Correct3 "Assess for the skin temperature using your hand. The area may feel initially warm, then cooler." Correct4 "Feel the skin for consistency. A boggy or edematous feel may indicate a Stage 1 pressure injury." Correct5 "Ask the patient if he or she has any pain or itchy sensation."

1,3,4,5 When assessing a patient with dark skin, the nurse should look for changes in skin color, such as skin that is darker (purplish, brownish, bluish) than surrounding skin. When assessing the area for skin temperature, the nurse should use his or her hand; the area may feel initially warm, then cooler. The nurse should touch the skin to feel its consistency; boggy or edematous feel may indicate a Stage 1 pressure injury. The nurse should ask the patient if he or she has any pain or itchy sensation. The nurse should use natural or halogen light source to accurately assess the skin color; fluorescent light casts blue color, which can make skin assessment difficult.

The nurse assesses a patient's wound and notes necrosis and absence of drainage. The nurse applies a hydrogel dressing to the wound to address which treatment goals? Select all that apply. 1 Maintaining a moist environment 2 Performing wound irrigations on a regular basis 3 Allowing visualization of the wound 4 Rehydrating wound tissue 5 Promoting autolytic debridement

1,4,5 Hydrogels are available in gels, gel-covered gauze, or sheets. They give moisture to a dry wound and maintain a moist environment. They can rehydrate wound tissue. Autolytic debridement can occur because of the moisturizing effects. The wound cannot be irrigated with a hydrogel dressing in place. A transparent film allows for visualization of the wound.

The nurse reviews the history of a patient with a major wound. The nurse identifies which factors that may result in delayed healing of the wound? Select all that apply. 1 Obesity 2 Hypertension 3 Hyperlipidemia 4 Diabetes mellitus 5 Long-term use of corticosteroid medication

1,4,5 Obesity decreases blood supply to the wound, causing delayed wound healing. Diabetes mellitus decreases collagen synthesis, retards early capillary growth, impairs phagocytosis, and reduces the supply of oxygen and nutrients secondary to vascular disease. Corticosteroid drugs impair phagocytosis by white blood cells, inhibit fibroblast proliferation and function, depress formation of granulation tissue, and inhibit wound contraction. Hypertension and hyperlipidemia do not have direct effects on wound healing.

The nurse performs a dressing change for a wound that is irregularly shaped and draining. Which type of dressing does the nurse apply that forms a nonsticky gel? 1 Foam 2 Alginate 3 Hydrogel 4 Semipermeable transparent film

2 Alginates form a nonsticky gel on contact with a draining wound. They are easy to use over irregularly shaped wounds and generally require a secondary dressing. Foams are sheets that hold large amounts of exudates and mostly require gauze wrapping. Hydrogels donate moisture to a dry wound and maintain a moist environment that rehydrates wound tissue. Semipermeable transparent films allow visualization of the wound and are minimally absorbent.

The nurse assesses a pressure ulcer on a hospitalized patient and uses digital photography to monitor wound progress. Which measure does the nurse take when obtaining the images? 1 Uses a flash for a clearer image of the patient's wound 2 Positions the patient the same way for each image 3 Uses a shiny underpad as a background for the wound to enhance the effect 4 Takes the image from a different angle each time to cover all aspects of the wound

2 If the patient is positioned in the same way for each image, the angle in which the photo is taken will not change; this will help record the wound progression correctly. It is important to avoid flash whenever possible because it may reflect off the wound and affect clarity. The wound should be shown on a solid background, not on shiny underpads, for clearer images. Taking the image from different angles each time would make it more difficult to accurately monitor wound progression.

A nursing professor, teaching about cellular response after tissue injury, asks a nursing student about the role of neutrophils. Which student response indicates that the student understands the information? 1 Neutrophils are the last to arrive at the injury site. 2 Neutrophils phagocytize bacteria and damaged cells. 3 Neutrophils are primarily involved in humoral immunity. 4 Neutrophils transform into macrophages after entering the tissue spaces.

2 Neutrophils are responsible for phagocytosis of bacteria and damaged cells at the site of injury. They are therefore first to arrive at the site. Lymphocytes, not neutrophils, are responsible for humoral immunity. Monocytes, not neutrophils, transform into macrophages after entering the tissue spaces.

A nursing student is learning about wound healing. Which statement made by the student indicates understanding of the process? 1 "Regeneration is more complex than the process of repair." 2 "Tertiary intention healing results in a larger and deeper scar." 3 "Delayed closure with sutures is a secondary intention healing." 4 "Primary intention healing takes place when wound margins are irregular."

2 Tertiary intention healing is a delayed suturing of a wound after the infection has been controlled. Because it is associated with delayed healing, the scar is larger and deeper than the scar that results from primary and secondary intention healing. The process of repair is more complex than the process of regeneration because repair occurs by primary, secondary, and tertiary intention. Secondary intention healing is the healing of wounds whose edges cannot be approximated. Delayed closure with sutures is a form of tertiary intention healing. Primary healing takes place when wound margins are clear and concise.

To prevent pressure injuries in a patient who spends most of the day in bed, which intervention does the nurse include in the patient's plan of care? 1 Allow the patient to determine an appropriate repositioning schedule. Correct2 Reposition the patient every hour. 3 Repositioning is not necessary with a thick foam mattress in place, because it conforms to the patient's body. 4 Place the patient on a doughnut-shaped ring for 15 minutes every one to two hours.

2 The caregivers should reposition patients often to prevent pressure injuries. The nurse should individualize time schedules and frequency based on risk factors, patient's overall condition, and type of mattress and support surface. For example, some high-risk paients may need to be turned and reposioned very hour, while others at lower risk may need to be turned and repositioned only every three to four hours. Allowing the patient to determine an appropriate repositioning schedule may not be appropriate to prevent pressure injuries; a patient may not "feel like" moving if experiencing fatigue, pain, etc. Devices to reduce pressure and shear (e.g., low-air-loss mattresses, foam mattresses, wheelchair cushions, padded commode seats, boots [foam, air], lift sheets) are used as appropriate; however, these devices do not replace the need for frequent repositioning. Placing patients on a doughnut-shaped ring only creates other areas of pressure and is not an appropriate intervention.

The nurse prepares a patient for discharge after an open appendectomy. The patient asks about the rationale for the six-week lifting restrictions. The nurse explains that the wound is in which stage of phase of healing during that time? 1 Repair phase 2 Maturation phase 3 Granulation phase 4 Regeneration phase

2 The maturation phase begins with scar contraction. It begins after seven days and may continue for several months or years. The fibroblasts disappear during this period, and the wound becomes stronger. Lifting heavy weights may tear the wound apart because of the pressure exerted. The repair, granulation, and regeneration phases occur before the maturation phase.

The nurse is providing care to a patient who is experiencing delayed healing of a surgical wound. The nurse asks which question to assess for nutritional deficiencies? 1 "Do you smoke cigarettes?" 2 "How much protein do you eat with each meal?" 3 "Do you monitor your blood glucose levels on a daily basis?" 4 "Are you currently taking a glucocorticoid drug for inflammation?"

2 When assessing for nutritional deficiencies related to delayed wound healing, the nurse should ask the patient about vitamin C, protein, and zinc consumption. Although smoking, poorly controlled blood glucose levels, and taking prescribed glucocorticoids can all delay wound healing, these questions are not appropriate when assessing the patient specifically for nutritional deficiencies.

A nursing professor, teaching about cellular response after tissue injury, asks a nursing student about the role of neutrophils. Which student response indicates that the student understands the information? 1 Neutrophils are the last to arrive at the injury site. Correct2 Neutrophils phagocytize bacteria and damaged cells. 3 Neutrophils are primarily involved in humoral immunity. 4 Neutrophils transform into macrophages after entering the tissue spaces.

2 Neutrophils are responsible for phagocytosis of bacteria and damaged cells at the site of injury. They are therefore first to arrive at the site. Lymphocytes, not neutrophils, are responsible for humoral immunity. Monocytes, not neutrophils, transform into macrophages after entering the tissue spaces.

The nurse is preparing to remove a dressing from a patient's deep wound for the first time since it was applied in surgery. The patient reports a desire to observe the procedure. Which emotion would the nurse most anticipate addressing with the patient? 1 Concern about infection 2 Fear of disfigurement 3 Anxiety about caring for the wound after discharge 4 Doubt in the nurse's ability to perform the procedure

2 The patient may be distressed at the thought or sight of an incision or wound because of fear of scarring or disfigurement. It is unlikely that the patient's main concern would be infection. It is doubtful that the patient will be concerned about care of the wound after discharge at this time; this can be addressed later. There is no information given that the nurse had an inappropriate facial expression that may have raised doubts about the nurse's ability to perform the procedure.Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.

The registered nurse (RN) collaborates with a licensed practical nurse (LPN) to create a plan of care for a patient with a wound on the bottom of a heel. The RN assigns which functions to the LPN? Select all that apply. 1 Create a diet plan to support wound healing. 2 Perform sterile dressing changes on the wound. 3 Teach the patient about care of the wound at home. 4 Develop a plan of care to accelerate wound healing. 5 Collect and record data about the wound's appearance.

2, 5 The role of the LPN is to perform sterile dressing changes and collect and record data about the appearance of the wound. Making a diet plan, developing a plan of care, and teaching the patient require advanced nursing judgment and should be performed by the RN.

The nurse is providing care for a patient with pressure ulcers who is bedridden. Which actions are taken by the nurse when cleansing the ulcers? Select all that apply. 1 Use hydrogen peroxide to clean the wound. 2 Use noncytotoxic solution to clean the wound. 3 After cleaning the wound, cover it with gauze dressing. 4 Irrigate the wound using a 30-mL syringe and 19-gauge needles. 5 Irrigate the wound by pouring the solution over the wound and dabbing it.

2,3,4 When cleaning pressure ulcers, use noncytotoxic solutions that do not kill or damage cells, especially fibroblasts. After cleaning, the wound should be covered with gauze dressing to protect it from infection. It is also important to use enough pressure to adequately clean the pressure ulcer without causing trauma or damage to the wound. To obtain this pressure, use a 30-mL syringe and a 19-gauge needle. Hydrogen peroxide is cytotoxic and therefore should not be used to clean pressure ulcers. The wound cannot be adequately cleansed if the solution is just poured and dabbed.

The nurse is caring for a patient two weeks after the patient sustained full-thickness burns. The patient has experienced a weight loss of 16 lbs (7.27 kg) since the burn injury occurred. The nurse makes which adjustments in the patient's dietary plan to ensure that metabolic requirements are being met? Select all that apply. 1 Low sodium diet Correct2 High protein intake 3 Low potassium diet Correct4 High carbohydrate intake Correct5 Adequate intake of water

2,4,5 The diet should be high in proteins to promote wound healing. High carbohydrate intake should be encouraged to help meet the high metabolic rate associated with burns. Fluid intake should be increased to compensate for the fluid loss. Sodium and potassium are restricted during the acute phase of a burn injury, not two weeks after the injury.

An unlicensed assistive personnel (UAP) tells the nurse, "While I was helping a patient with perineal care, I noticed feces coming out of her vagina." Which action does the nurse take first? 1 Notify the health care provider. 2 Document the fistula formation. 3 Assess the patient and vaginal drainage. 4 Apply a dressing to the vagina

3 A fistula may have formed between the bowel and the vagina. The nurse first should assess the patient and the drainage from the vagina. Then the nurse should notify the health care provider, document the occurrence and care prescribed, provide care prescribed, and document the care and patient response.

The nurse assesses a patient who has a tumorlike mass of scar tissue that extends beyond the edges of an abdominal scar. The scar is from a surgery that occurred several years prior to the patient's current visit. Which term does the nurse use to document the assessment finding? 1 Adhesion 2 Evisceration 3 Keloid formation 4 Fistula formation

3 A keloid formation is a great protrusion of scar tissue that extends beyond the wound edges and may form tumorlike masses of scar tissue; therefore this is the term the nurse uses when documenting the patient's assessment data. Adhesions are bands of scar tissue that form between or around organs (such as the lungs or abdominal organs). Evisceration occurs when wound edges separate to the extent that intestines protrude through the wound. A fistula formation is an abnormal passage between organs or a hollow organ and skin (such as abdominal or perianal fistula).

A patient is hospitalized with a pressure ulcer with full-thickness skin loss involving damage to subcutaneous tissue. Which stage of pressure injury does the nurse document? 1 Stage 1 2 Stage 2 3 Stage 3 4 Stage 4

3 Stage 3 pressure ulcers are defined as full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Stage 1 ulcers have intact skin with nonblanchable redness of a local area with a change in skin temperature, tissue consistency, or sensation. Stage 2 ulcers are partial-thickness with a red-pink wound bed. Stage 4 ulcers involve extensive destruction of tissue with exposed bone, tendon, or muscle.

An older patient is hospitalized with a black wound on the heel. Which initial treatment does the nurse expect the plan of care to include? 1 Apply an absorbent dressing to absorb exudate. 2 Let the wound open to air for 24 hours to allow it to dry out. 3 Debride the nonviable, eschar tissue to allow healing. 4 Prepare for negative-pressure wound therapy to facilitate healing.

3 With a black wound, the therapy prescribed is usually debridement (surgical, mechanical, autolytic, or enzymatic) to prepare the wound bed for healing. Black wounds may have purulent drainage, but debridement is done first. It is not recommended to let a wound that has the potential to heal dry out. Dryness is an enemy of wound healing. It must be kept slightly moist to heal. The negative-pressure wound (vacuum) therapy is used to remove drainage and is more likely to be used after debridement.Test-Taking Tip: Try putting questions and answers in your own words to test your understanding.

The nurse assesses that there is fecal material drainage coming from an abscess in the perianal area. Which complication of wound healing does the nurse suspect has occurred? 1 Evisceration 2 Keloid formation 3 Fistula formation 4 Hypertrophic scars

3 Wound healing is the process in which the skin or other body tissue repairs itself after injury. Fistula is a complication of wound healing in which an abnormal passage is formed between organs or a hollow organ and skin. Evisceration is a complication of wound healing that occurs when wound edges separate to the extent that intestines protrude through the wound. Hypertrophic scars are inappropriately large, red, raised, and hard scars that occur due to overabundance of collagen during healing. Keloid extends beyond the edges of the wound and may form tumorlike masses of scar tissue.Test-Taking Tip: Do not worry if you select the same numbered answer repeatedly, because there usually is no pattern to the answers.

The nurse is caring for a patient at risk for developing a pressure ulcer. Which nursing action is included in the plan of care to prevent the development of pressure ulcers? 1 Sliding the patient instead of lifting when turning 2 Repositioning the patient on a doughnut ring every three to four hours 3 Applying lotion after the patient bathes and vigorously massaging the skin 4 Implementing a schedule to reposition every one to two hours

4 A turning schedule including proper documentation is the best way to ensure that the patient is repositioned every one to two hours. Sliding instead of lifting the patient causes friction and may result in skin tears. Placing a patient on a doughnut ring is contraindicated because it results in an area of pressure, and three to four hours is too long between changes of position. Lotion applied to the skin does provide moisture, but vigorous massage may cause tissue damage.

The nurse reviews the plan of care for a patient with a stage 3 sacral pressure ulcer that was debrided. The nurse questions which of the following items that is listed on the plan? 1 Provide negative-pressure wound therapy. 2 Turn and position the patient every two hours. 3 Assess for pain and medicate before dressing change. 4 Clean the ulcer every shift with povodone-iodine (Betadine) solution.

4 Topical antimicrobials and antibactericidals (e.g., povidone-iodine, Dakin's solution [sodium hypochlorite], hydrogen peroxide [H2O2], chlorhexidine [Hibiclens]) should be used with caution in wound care because they can damage the new epithelium of healing tissue and delay healing. These topicals should never be used in a clean, granulating wound. It is appropriate to assess for pain and medicate before changing the dressing, turn the patient every two hours, and implement negative-pressure wound therapy.