Lewis Med-Surg Ch. 12 Inflammation and Wound Healing

The nurse reviews a list of medications used to treat inflammation. Which medication promotes healing by reducing capillary permeability? a. Aspirin b. Piroxicam c. Ibuprofen d. Acetaminophen

A. Aspirin Aspirin is an anti inflammatory drug that reduces capillary permeability in the body. Piroxicam is a non steroidal anti inflammatory drug that inhibits the synthesis of prostaglandin. Ibuprofen is a nonsteroidal antiinflammatory drug that inhibits prostaglandin synthesis. Acetaminophen helps maintain thermoregulation by acting on the heat regulating center in the hypothalamus. pg 184

The nurse is reviewing the labs of a patient who has been admitted for a stab wound to the abdomen. Which finding is likely to be seen in the report? a. Leukocytosis b. Albuminuria c. Polycythemia d. Thrombocythemia

A. Leukocytosis Leukocytosis results from an increase in the release of WBCs from the bone marrow as a result of inflammation in response to the stab wound . Albuminuria is the presence of albumin in urine, which would not be present due to this type of injury. Polycythemia is an increase in the RBC count and thrombocythemia is a relative increase of platelets in the blood; neither of these conditions would be present after a wound associated with potential bleeding. pg 182

The nurse assesses four patients and determines that the patient with which condition will likely experience fibrinous inflammatory exudate? a. Venous ulcer b. Pleural effusion c. Bleeding after surgery d. Runny nose due to laryngitis

A. Venous ulcer Fibrinous exudate occurs in venous ulcers because of increased vascular permeability and fibrinogen leakage into interstitial spaces. Pg 182

A patient's temperature has been 101° F (38.3° C) for several days. The patient's normal caloric intake to meet nutritional needs is 2000 calories per day. Knowing that the metabolic rate increases 7% for each Fahrenheit degree above 100° in body temperature, how many total calories should the patient receive each day?

ANS: 2140 calories DIF: Cognitive Level: Apply (application)

A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions? (Put a comma and a space between each answer choice [A, B, C, D]). a. Administer IV antibiotics. b. Sponge patient with cool water. c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol).

ANS: A, D, B, C The first action should be to administer the antibiotic because treating the infection that has caused the fever is the most important aspect of fever management. The next priority is to lower the high fever, so the nurse should administer acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower the temperature further. The wet-to-dry dressing change will not have an immediate impact on the infection or fever and should be done last. DIF: Cognitive Level: Analyze (analysis)

A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse's highest priority? a. Maintaining the patient's blood glucose within a normal range b. Ensuring that the patient has an adequate dietary protein intake c. Giving antipyretics to keep the temperature less than 102° F (38.9° C) d. Redressing the surgical incision with a dry, sterile dressing twice daily

ANS: A Elevated blood glucose will have an impact on multiple factors involved in wound healing. Ensuring adequate nutrition is also important for the postoperative patient, but a higher priority is blood glucose control. A temperature of 102° F will not impact adversely on wound healing, although the nurse may administer antipyretics if the patient is uncomfortable. Application of a dry, sterile dressing daily may be ordered, but frequent dressing changes for a wound healing by primary intention is not necessary to promote wound healing. DIF: Cognitive Level: Analyze (analysis)

Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative-pressure wound therapy? a. Low serum albumin level b. Serosanguineous drainage c. Deep red and moist wound bed d. Cobblestone appearance of wound

ANS: A With negative pressure therapy, serum protein levels may decrease, which will adversely affect wound healing. The other findings are expected with wound healing. DIF: Cognitive Level: Analyze (analysis)

After receiving a change-of-shift report, which patient should the nurse assess first? a. The patient who has multiple leg wounds with eschar to be debrided b. The patient receiving chemotherapy who has a temperature of 102° F c. The patient who requires analgesics before a scheduled dressing change d. The newly admitted patient with a stage IV pressure ulcer on the coccyx

ANS: B Chemotherapy is an immunosuppressant. Even a low fever in an immunosuppressed patient is a sign of serious infection and should be treated immediately with cultures and rapid initiation of antibiotic therapy. The nurse should assess the other patients as soon as possible after assessing and implementing appropriate care for the immunosuppressed patient. DIF: Cognitive Level: Analyze (analysis)

When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing? a. The patient has had the heel ulcers for 6 months. b. The patient takes oral hypoglycemic agents daily. c. The patient states that the ulcers are very painful. d. The patient has several incisions that formed keloids.

ANS: B The use of oral hypoglycemics indicates diabetes, which can interfere with wound healing. The persistence of the ulcers over the past 6 months is a concern, but changes in care may be effective in promoting healing. Keloids are not disabling or painful, although the cosmetic effects may be distressing for some patients. Actions to reduce the patient's pain will be implemented, but pain does not directly affect wound healing. DIF: Cognitive Level: Analyze (analysis) Apply

After the home health nurse teaches a patient's family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed? a. The family member uses a lift sheet to reposition the patient. b. The family member uses clean tap water to clean the wound. c. The family member dries the wound using a hair dryer on a low setting. d. The family member places contaminated dressings in a plastic grocery bag.

ANS: C Pressure ulcers need to be kept moist to facilitate wound healing. The other actions indicate a good understanding of pressure ulcer care. DIF: Cognitive Level: Apply (application)

The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? a. Blood glucose of 136 mg/dL b. Oral temperature of 101° F (38.3° C) c. Separation of the proximal wound edges d. Patient complaint of increased incisional pain

ANS: C Wound separation 3 days postoperatively indicates possible wound dehiscence and should be immediately reported to the health care provider. The other findings will also be reported but do not require intervention as rapidly. DIF: Cognitive Level: Analyze (analysis)

The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)? a. The patient who reports increased tenderness and swelling around a leg wound b. The patient who was just admitted after suturing of a full-thickness arm wound c. The patient who needs teaching about home care for a draining abdominal wound d. The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer

ANS: D LPN/LVN education and scope of practice include sterile dressing changes for stable patients. Initial wound assessments, patient teaching, and evaluation for possible poor wound healing or infection should be done by the registered nurse (RN). DIF: Cognitive Level: Apply (application)

Which question would the nurse ask who is experiencing delayed healing of a surgical wound to assess for nutritional deficiencies? a. Do you smoke? b. How much protein do you consume per meal? c. Do you monitor your blood glucose on a daily basis? d. Are you currently taking a glucocorticoid drug for inflammation?

B. How much protein do you consume per meal? When assessing for nutritional deficiencies related to delayed wound healing, ask the patient about Vitamin C, protein, and zinc consumption. Pg 188

The nurse determines that a hospitalized patient is at risk for the development of pressure injuries. Which intervention does the nurse include in the plan of care to reduce the risk? a. Encourage increased intake of juices b. Reposition the patient every hour c. Massage bony prominences once per shift d. Clean the sin once per day with hydrogen peroxide

B. Reposition the patient every hour Repositioning helps to prevent pressure injuries. Repositioning time schedules and frequency should be based on risk factors, the patients overall condition, and the type of mattered and support surface. Pg 195

A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C) The patient reports having no discomfort. Which action by the nurse is appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Check the patient's temperature again in 4 hours. d. Give acetaminophen (Tylenol) prescribed PRN for pain.

C. Check the patients temperature again in 4 hours Mild to moderate temperature elevations (<103° F) do not harm young adult patients and may benefit host defense mechanisms. The nurse should continue to monitor the temperature. Antipyretics are not indicated unless the patient is complaining of fever-related symptoms, and the patient does not require analgesics if not reporting discomfort. There is no need to notify the patient's health care provider or to use a cooling blanket for a moderate temperature elevation.

A patient being treated for inflammation receives a medication that promotes healing by preventing the liberation of lysosomes. The nurse recognizes that which drug has this MOA? a. Ibuprofen b. Piroxicam c. Corticosteroid d. Acetaminophen

C. Corticosteroid Costeroids are anti inflammatory drugs that interfere with tissue granulation and induce immunosuppressive effects; thus this type of drug prevents the liberation of lysosomes. Pg 184

Which condition is an example of chronic inflammation? Select all that apply. a. Nephritis b. Infection c. Fibromyalgia d. Cholecystitis e. Psoriasis

C. Fibromyalgia e. Psoriasis Nephritis, infection, and cholecystitis are examples of acute inflammation. pg 183

Which information documented by the nurse concerning a pressure injury is subjective? a. Edema b. Discoloration c. Pain d. Moderate purulent drainage

C. Pain Reports of pain are considered subjective because the nurse cannot measure and observe pain beyond the patient's report.

A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? a. Skin flushing b. Muscle cramps c. Rising body temperature d. Decreasing blood pressure

C. Rising body temperature The patient's complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with a rising temperature.

A patient receives instructions for treating a sprained wrist that include elevating the injured extremity above the level of the heart. The nurse questions the recommission for elevation when discovering which condition in the patient's medical history? A. Diabetes b. Cancer c. Significantly reduced arterial circulation d. Routine high dosed NSAID use

C. Significantly reduced arterial circulation Elevation maybe contraindicated in patients with significantly reduced arterial circulation. Elevation of injured extremity above the level of the heart is often prescribed to reduce edema at the inflammatory site by increasing venous and lymphatic return. Elevation helps reduce pain associated with blood engorgement at the injury site. Pg 184- 185

A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient? a. Monitor white blood cell counts. b. Check the skin for areas of redness. c. Measure the temperature every 2 hours. d. Ask about feelings of fatigue or malaise.

D. Ask about feelings of fatigue or malaise The earliest manifestation of an infection may be "just not feeling well." Common clinical manifestations of inflammation and infection are frequently not present when patients receive immunosuppressive medications.

A patient presents with a runny nose associated with an upper respiratory infection. Which type of inflammatory exudate does the nurse expect to see? a. Purulent b. Fibrinous c. Serosanguinous d. Catarrhal

D. Catarrhal Catarrhal exudate is found in tissues where cells produce mucus; the inflammatory response accelerates mucus production. Pg 182

A patient with a large pressure injury on the heel reports new inflammation in the surrounding subcutaneous tissue. Which term describes the condition that the patient is experiencing? a. Sepsis b. Keloid c. Fistula d. Cellulitis

D. Cellulitis Cellulitis can occur due to untreated pressure injuries and involves the spreading of inflammation to subcutaneous (connective) tissue. Pg 193

A patient with an arm sprain asks the nurse about the benefit of heat application. Which rationale does the nurse provide? a. It decreases congestion. b. It promotes vasoconstriction c. It prevents further tissue injury. d. It localizes the inflammatory agents

D. It localizes the inflammatory agents. Heat may be used later (after 24 to 48 hours) to promote healing by increasing the circulation to the inflamed site and the subsequent removal of debris. Heat is used to localize the inflammatory agents. Cold application decreases congestion and promotes vasoconstriction at the site of inflammation. Pg 191

The nurse assesses the fluid found in a patient's surgical drain. Which characteristic leads the nurse to describe the inflammatory exudate as serosanguinous? a. Presence of mucus b. Gelatinous ribbons c. Liquefied dead cells d. Semi clear pink appearance

D. Semi clear pink appearance Serosanguineous inflammatory exudate is composed of red blood cells and has a semi clear pink appearance. pg. 182

In which order do the four stages of pressure injury occur? full thickness skin loss full thickness skin and tissue loss non blanchable erythema of intact skin partial thickness skin loss with exposed dermis

Stage1: Non blanchable erythema of intact skin Stage: partial thickness skin loss with exposed dermis Stage 3: full thickness skin loss Stage 4: full thickness skin and tissue loss Pg 194

The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer? a. Administer prescribed PRN hydrocodone 30 minutes before the change. b. Pour sterile saline onto the new dry dressings after the wound has been packed. c. Apply antimicrobial ointment before repacking the wound with moist dressings. d. Soak the old dressings with sterile saline 30 minutes before the dressing change

a. Administer prescribed PRN hydrocodone 30 minutes before the change. Mechanical debridement with wet-to-dry dressings is painful, and patients should receive pain medications before the dressing change begins. The new dressings are moistened with saline before being applied to the wound but not soaked after packing. Soaking the old dressings before removing them will eliminate the wound debridement that is the purpose of this type of dressing. Application of antimicrobial ointments is not indicated for a wet-to-dry dressing.

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate? a. Elevate the ankle above heart level. b. Apply a warm moist pack to the ankle. c. Ask the patient to try bearing weight on the ankle. d. Assess the ankle's passive range of motion (ROM).

a. Elevate the ankle above heart level. Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase swelling and risk further injury. Cold packs should be applied the first 24 hours to reduce swelling. The nurse should not ask the patient to move or bear weight on the swollen ankle because immobilization of the inflamed or injured area promotes healing by decreasing metabolic needs of the tissues.

The patient with a difficult to heal wound is scheduled for hyperbaric oxygen therapy. How will this treatment help the patient? Select all that apply. a. Kills anaerobic bacteria b. Prevents formation of new blood vessels c. Slows down formation of granulation tissue d. Increases the effectiveness of certain antibiotics e. Increases the killing power of WBCs

a. Kills anaerobic bacteria d. Increases the effectiveness of certain antibiotics e. Increases the killing power of WBCs HBOT involves delivering O2 at increased atmospheric pressure. The therapy kills anaerobic bacterial in a wound, preventing further infection. It increases the effectiveness of certain antibiotics and the killing power of WBCs. The therapy also promotes angiogenesis (growth of new blood vessels) to facilitate wound healing. HBOT also accelerates formation of granulation tissue, which in turn accelerates the wound healing process. Pg 191

Which factor may result in delayed healing of a major wound? a. Obesity b. Hypertension c. Hyperlipidemia d. Diabetes mellitus e. Long term use of corticosteroid medication

a. Obesity d. Diabetes mellitus e. Long term use of corticosteroid medication Obesity decreases blood supply to the wound. Diabetes mellitus decreases collagen synthesis, retards early capillary growth, impairs phagocytosis, and reduces the supply of O2 and nutrients secondary to vascular disease. Corticosteroid drugs impair phagocytosis by WBCs, inhibit fibroblast proliferation and function, depress formation of granulation tissue, and inhibit wound contraction. Pg 188

A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/µL and a band count of 11%. What prescribed action should the nurse take first? a. Obtain cultures of the wound. b. Begin antibiotic administration. c. Continue to monitor the wound for drainage. d. Redress the wound with wet-to-dry dressings.

a. Obtain cultures of the wound. The increase in WBC count with the increased bands (shift to the left) indicates that the patient probably has a bacterial infection, and the nurse should obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well.

The nurse uses an Aquaform hydrogel dressing to cover a necrotic wound. What are the advantages compared to other dressings? a. Rehydrates wound tissue b. Maintains moist environment c. Soothing effect in a painful wound d. Holds large amount of exudates e. Allows visualization of the wound

a. Rehydrates wound tissue b. Maintains moist environment c. Soothing effect in a painful wound The hydrogel dressing donates moisture to the wound and rehydrates the wound tissue. It helps to keep the wound environment moist so that debridement occurs by a moisturizing effect. Pg 189

A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care? a. The new nurse cleans the ulcer with half-strength peroxide. b. The new nurse uses a hydrocolloid dressing (DuoDerm)on the ulcer. c. The new nurse irrigates the pressure ulcer with saline using a 30-mL syringe. d. The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer.

a. The new nurse cleans the ulcer with half-strength peroxide. Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions by the new nurse are appropriate.

The nurse provides care for a patient with a surgical would and identifies that which vitamin will accelerate epithelialization? a. Vitamin A b. Vitamin C c. Vitamin D d. B-complex vitamins

a. Vitamin A Vitamin A accelerates epithelialization by combining with with collagen shields of the skin. Pg 184

A patient diagnosed with osteomyelitis exhibits malaise but no other manifestations of inflammation. Which drug therapy does the nurse determine may be causing this atypical response? a. Salicylates b. Corticosteroids c. Vitamin d supplements d. Potassium supplements

b. Corticosteroids Corticosteroids are used to treat osteomyelitis. They suppress immunity and mask classic manifestations of inflammation; thus the patient would present with malaise. Salicylates are used to reduce excessive body temperature and do not interfere with the immune mechanism. Vitamin D supplements facilitate calcium absorption. Potassium can strengthen the functions of immune system.- pg 183

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. Assess the wound every 2 hours.

b. Document the assessment. The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention. The nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is progressing normally.

The nurse develops a plan of care for a patient with a soft tissue injury to the arm. Which nursing intervention is included in the plan? a. Perform ROM to promote circulation b. Elevate the arm above the heart to reduce pain c. Avoid compression bandages to minimize impairment of the nerves d. Apply heat for the first 24 hours to promote healing

b. Elevate the arm above the heart to reduce pain An injured extremity may become engorged with blood. Elevation of the injured extremity above the heart helps to reduce pain associated with swelling by increasing venous and lymphatic return. The extremity would be immobilized to promote healing by decreasing the metabolic needs in the patient. pg 184- 185

Which systemic clinical manifestation does the nurse anticipate finding in a patient who has inflammation at an injury site? Select all that apply. A. Hct (hematocrit) of 46% b. Pulse 120 beats/min c. WBC of 13,000/uL d. RR 10 breaths/min e. Temp of 101 F

b. Pulse 120 beats/min c. WBC of 13,000/uL e. Temp of 101 F The clinical manifestations of inflammation at the injury site are increased pulse and respiratory rate; increased WBC; increased body temp; and anorexia. Normals: Temp: 97.6- 99.6 RR: 12 to 20 breaths/min HR: 60 to 100 beats/min WBC 4000- 11,000/uL Hct: 45 to 52% men; 37 to 48% women pg 182

The nurse determines that a patient with a leg injury is experiencing local inflammation based on which assessment finding? a. Odor at the site b. Swelling at the site c. Redness at the site d. Purulent from the site e. Loss of cellular function at the site

b. Swelling at the site c. Redness at the site e. Loss of cellular function at the site Inflammation causes a shifting of fluids to interstitial spaces and fluid accumulation, resulting in swelling at the site. Inflammation increases the permeability of the blood vessels by causing vasodilation, resulting in redness at the site. Swelling and pain can result in loss of cellular function at the inflammatory site. Odor and purulent exudate at the site are signs of infection. pg 182

A young male patient with paraplegia has a stage II sacral pressure ulcer and is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family? a. Change the patient's bedding frequently. b. Apply a hydrocolloid dressing over the ulcer. c. Change the patient's position every 1 to 2 hours. d. Record the size and appearance of the ulcer weekly.

c. Change the patient's position every 1 to 2 hours. The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The other interventions may also be included in family teaching.

The nurse determines that a patients abdominal surgical wound is healing by primary intention. Which phase consists of the migration of fibroblasts? a. Initial phase b. Maturation phase c. Granulation phase d. Regeneration phase

c. Granulation phase The migration of fibroblasts occurs in the granulation phase, which lasts from 5 days to 4 weeks. In this phase, collagen is secreted and there is an abundance of capillary buds in the wound, making it fragile. Pg 185

A patient's 4 x 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound? a. Dry gauze dressing b. Nonadherent dressing c. Hydrocolloid dressing d. Transparent film dressing

c. Hydrocolloid dressing The wound requires debridement of the necrotic areas and absorption of the yellow-green slough. A hydrocolloid dressing such as DuoDerm would accomplish these goals. Transparent film dressings are used for clean wounds or approximated surgical incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb wound drainage or debride the wound.

Which lab result will make the nurse suspect that a patient may be experiencing an acute bacterial infection? a. Increased platelet count b. Increased BUN c. Increased number of band neutrophils d. Increased number of segmented myelocytes

c. Increased number of band neutrophils When the demand for neutrophils increases to the extent that the bone marrow releases immature forms of neutrophils (bands) into circulation, this is called a shift to the left. It is common in patients with acute bacterial infections. Platelets increase with tissue damage through the inflammatory process and for healing, but they are not the best indicator of infection. BUN is unrelated to infection unless it is in the kidney. Myelocytes increase with infection and mature to form band neutrophils, but they are not segmented. The mature neutrophils are segmented. Pg. 180

The HCP states, "the wound will be allowed to heal by secondary intention." What does the nurse understand this to mean? a. The wound will be stapled together until it heals B. Healing will contract the area to close the wound c. It will be left open and heal from the edges inward d. Sutures will be inserted after the current infection is controlled

c. It will be left open and heal from the edges inward Secondary healing- the wound is left open and heals from the edges inward and from the bottom up. Primary intention- the wound edges are stapled or sutured, and healing occurs until the contraction of the healing area closes the defect and brings the skin edges closer together to form a mature scar. Tertiary healing- the contaminated wound is left open and closed after the infection is controlled. Pg 186

The nurse is preparing for the discharge of a patient with a pressure injury and includes the caregiver. Which information will the nurse include in the home care instructions? a, reposition the patient every 20 mins b. Inspect the skin of the patient every 5 days c. Teach the caregiver the "no touch" technique for changing the dressing d. Dispose of contaminated dressings along with other garbage.

c. Teach the caregiver the "no touch" technique for changing the dressing The no touch technique is important in preventing wound contamination. Pg 196

When a patient takes a prednisone for rheumatoid arthritis, which lab result does the nurse expect to find? a. Increased prothrombin time b. Increased RBC c. Decreased serum protein levels d. Decreased WBC

d. Decreased WBC Prednisone is a corticosteroid drug that interferes with the synthesis of lymphocytes, resulting in a decreased WBC count. Pg 184

The nurse should plan to use a wet-to-dry dressing for which patient? a. A patient who has a pressure ulcer with pink granulation tissue b. A patient who has a surgical incision with pink, approximated edges c. A patient who has a full-thickness burn filled with dry, black material d. A patient who has a wound with purulent drainage and dry brown areas

d. A patient who has a wound with purulent drainage and dry brown areas Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue.

During a follow up visit post breast reduction, the patient reports soft, pink tissue that protrudes above the surface of the healing wound. Which complication of wound healing would the nurse recognize? a. Adhesion b. Contractions c. Keloid formation d. Excess granulation tissue

d. Excess granulation tissue Pg 187d. Excess granulation tissued.

The nurse evaluates wound healing in a patient with an arm laceration. The nurse recalls that which deficiency may cause insufficient collagen production by fibroblasts? a. Zinc b. Protein c. Vitamin B d. Vitamin C

d. Vitamin C Vitamin C is needed for capillary synthesis and collagen production by fibroblasts. Pg 188, 191

Which treatment option would the nurse describe to the patient who is to undergo mechanical debridement of a wound? A. Semiocclusive dressing application b. Topical application of collagenase c. Surgical removal of eschar d. Wet to dry dressing e. Wound irrigation

d. Wet to dry dressing e. Wound irrigation There are four types of debridement: surgical, mechanical, automatic, and enzymatic. See purple box Table 12.15 pg 190