Wounds-Chapter 11: Inflammation and Healing

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?

"How much protein do you eat with each meal?" When assessing for nutritional deficiencies related to delayed wound healing, the nurse should ask the patient about vitamin C, protein, and zinc consumption.

A patient asks the nurse what the health care provider meant by "the wound will be allowed to heal by secondary intention." How does the nurse respond?

"The wound will be left open and heal from the edges inward." With secondary healing, the wound is left open and heals from the edges inward and from the bottom up.

A patient asks the nurse what the health care provider meant by "the wound will be allowed to heal by secondary intention." How does the nurse respond?

"The wound will be left open and heal from the edges inward." With secondary healing, the wound is left open and heals from the edges inward and from the bottom up. With 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. With tertiary healing, the contaminated wound is left open and closed after the infection is controlled.

Which would the nurse include when teaching a patient about how to promote healing following abdominal surgery? Select all that apply.

- Increase the intake of protein and vitamins C, B, and A to facilitate healing. - Notify the health care provider of redness, swelling, and increased drainage Fluid is needed to replace fluid from insensible loss and from exudates as well as the increased metabolic rate. Protein corrects the negative nitrogen balance that results from the increased metabolic rate and that is needed for synthesis of immune factors and healing. Vitamin C helps synthesize capillaries and collagen. B-complex vitamins facilitate metabolism. Vitamin A aids in epithelialization. The health care provider should be notified if there are signs of infection

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.

-"It kills anaerobic bacteria." -"It increases the effectiveness of certain antibiotics." -"It increases the killing power of white blood cells (WBCs)."

The nurse reviews patients' medical records to assess for the potential for developing pressure ulcers. The nurse determines that which patients are at highest risk? Select all that apply.

-A 65-year-old female; quadriplegia; nonambulatory -A 49-year-old male; sepsis; minimal verbal response -A 58-year-old female; stroke; incontinence of urine and stool

The nurse provides education for a group of nursing students about the assessment of pressure ulcers in older patients. Which information would the nurse include? Select all that apply.

-Assess all patients at risk for pressure injury at the time of the first hospital visit -In the acute care setting, assess on a regular basis (every 24 hours) -Assess for factors that may delay wound healing -Assess initial wounds for size, depth, color, and drainage

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.

-Extracting wound fluid from deep tissue layers -Rotating a culture swab over a cleansed 1 cm area near the center of the wound 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.

Which type of primary dressing would the nurse select for a patient whose wound has moderate-to-heavy exudate? Select all that apply

-Foam dressing -Foam dressing 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.

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.

-High-protein intake -High-carbohydrate intake -Adequate intake of water 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.

A patient is involved in a motor vehicle accident which resulted in multiple lacerations. To promote wound healing, the nurse includes which dietary instructions in the patient's discharge teaching? Select all that apply.

-Include foods rich in vitamin C -Include foods rich in vitamin B12 -Consume adequate quantities of water.

A patient is being discharged from a health care facility following an abdominal cholecystectomy. Which instructions related to wound care does the nurse provide to the patient? Select all that apply.

-Increase fluid intake -Consume a high-protein diet -Observe the wound for complications -Follow aseptic procedures during dressing change. The patient should increase fluid intake to replace fluid loss from perspiration, exudate formation, and increased metabolic rate. The patient should consume a diet high in protein, carbohydrate, and vitamins with moderate fat to promote healing. The nurse should teach the patient aseptic procedures to keep the wound free from infection. The nurse should also teach the patient to observe and notify the health care provider about any complications in the wound. The patient should take vitamin B supplements to prevent deficiency, which could disrupt metabolism of protein, fat, and carbohydrate. The nurse should inform the patient of the need to continue the drugs for the prescribed time to prevent occurrence of drug-resistant organisms.

Implement a one-hour turning schedule with skin assessment

-Maintaining a moist environment -Rehydrating wound tissue -Rehydrating wound tissue 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.

The nurse identifies that which treatments may be considered for a patient with an acute wound? Select all that apply.

-Negative-pressure wound therapy (NPWT) -Drug therapy using becaplermin -Hyperbaric O2 therapy (HBOT) NPWT is used to treat acute and chronic wounds. A vacuum source creates continuous or intermittent negative pressure inside the wound to remove fluid, exudates, and infectious materials to prepare the wound for healing and closure. Platelet-derived growth factor is released from the platelets and stimulates cell proliferation and migration; becaplermin is a recombinant human platelet-derived growth factor gel that actively stimulates wound healing. HBOT is the delivery of O2 at increased atmospheric pressures. It can be given topically by creating a chamber around the injured limb.

The nurse is caring for a patient who has an abdominal wound. Which factors place the patient at an increased risk of wound dehiscence? Select all that apply.

-Obesity -Infection -Seroma formation Obesity, presence of infection, and seroma formation between the margins of the wound may increase the risk of wound dehiscence. People who are obese are at high risk for dehiscence because adipose tissue has less blood supply and may slow healing. Infection causes an inflammatory process. The granulation tissue formed may not be strong enough to withstand forces imposed on the wound. Seroma, a pocket of fluid formed between tissue layers, prevents the edges of the wound from coming together.

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.

-Perform sterile dressing changes on the wound. -Collect and record data about the wound's appearance

The registered nurse observes a new graduate nurse performing a wound assessment. The registered nurse questions which steps of the procedure performed by the new graduate nurse? Select all that apply.

-Placing a cotton-tipped applicator in the wound and notes a "lip" around the wound; documents as undercurrent -Using inches when measuring the wound

The nurse uses an Aquaform hydrogel dressing to cover a patient's necrotic wound. Which advantages does this type of dressing have when compared to other dressings? Select all that apply.

-Rehydrates wound tissue -Rehydrates wound tissue -Donates moisture to dry wound The hydrogel dressing donates moisture to the wound and rehydrates the wound tissue. The dressing helps to keep the wound environment moist so that debridement occurs by a moisturizing effect. The hydrogel dressing does not allow visualization of the wound, because it is not transparent. The hydrogel dressing does not contain foam; therefore it cannot hold large amounts of exudates.

A patient is admitted to the hospital with full-thickness burns to the lower extremity and has developed eschar formation. The nurse recalls that which procedures remove eschar to accelerate the healing process? Select all that apply.

-Surgical escharotomy -Enzymatic debridement -Mechanical debridement Eschar can be removed by surgical escharotomy, enzymatic debridement, and mechanical debridement. -Surgical escharotomy involves removal of eschar by making a full-length incision on the eschar. -In enzymatic debridement, the removal of necrotic tissues is done using an enzymatic preparation. -Mechanical debridement involves removal of damaged dead tissues and cellular debris physically.

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.

-Use noncytotoxic solution to clean the wound. -After cleaning the wound, cover it with gauze dressing -Irrigate the wound using a 30-mL syringe and 19-gauge needles 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

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?

Fear of disfigurement The patient may be distressed at the thought or sight of an incision or wound because of fear of scarring or disfigurement.

In which order do the four stages of pressure injuries to the tissue occur?

1. Non-blanchable erythema of intact skin 2. Partial-thickness skin loss with exposed dermis 3. Full-thickness skin loss 4. Full-thickness skin-and-tissue loss

The nurse is caring for a patient who is scheduled to receive negative-pressure wound therapy (NPWT). Which is the correct order of the steps taken when initiating NPWT?

1.The wound is cleaned 2.A gauze dressing is cut to the dimensions of the wound 3.A large occlusive dressing is applied 4.A small hole is made over the gauze where the tubing is attached. 5.The tubing is attached to a pump, which creates a negative pressure in the wound bed

The nurse provides postoperative care for an older patient with asthma six hours after a hernia repair. Assessment findings include the following: body temperature 103.2°F, pulse 99/min, and BP 100/70 mm Hg. Which is the most effective nursing intervention?

Administer antipyretic drugs around the clock Because the patient is an older adult and has pulmonary disease, use of antipyretic drugs should be considered to lower the temperature to a particular set point

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?

Assess the patient and vaginal drainage 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 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?

Clean the ulcer every shift with povodone-iodine (Betadine) solution 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.

The nurse is caring for a patient with a wound that contains nonviable tissue. Which treatment does the nurse administer?

Debride eschar tissue The treatment of nonviable tissue is debridement of the eschar tissue. Eschar is dead tissue that sheds or falls off from healthy skin.

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?

Debride the nonviable, eschar tissue to allow healing. 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.

During the assessment of a patient with an abdominal incision, the nurse notes that the wound edges have separated and the intestines are close to the surface. Which term does the nurse use when documenting this data?

Evisceration Evisceration occurs when wound edges separate to the extent that intestines protrude through the wound; therefore the nurse would use this term when documenting the patient's assessment data.

During a follow-up visit following a breast reduction, a patient reports soft, pink tissue that protrudes above the surface of the healing wound. The nurse recognizes the condition as which complication of wound healing?

Excess granulation tissue The condition is referred to as excess granulation tissue, or "proud flesh," a complication of wound healing. It is defined as excess granulation tissue that protrudes above the surface of a healing wound

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?

Fistula formation 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.

During a patient's postoperative follow-up visit, the nurse notes that the patient's wound is pink and vascular with numerous red granules. In which stage of healing is the wound?

Granulation phase

The nurse determines that a patient's abdominal surgical wound is healing by primary intention. Which phase best describes the migration of fibroblasts?

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

The nurse plans which intervention for an older adult patient who is assessed to have a score of 16 on the Braden scale?

Implement a one-hour turning schedule with skin assessment

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?

Implementing a schedule to reposition every one to two hours

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?

Initial 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

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?

It impedes blood flow to healing areas. Cigarettes contain nicotine, which is a potent vasoconstrictor, and thus impedes blood flow to healing areas and delays wound healing

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?

Keloid formation 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

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?

Keloid formation 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.

The nurse is reviewing the laboratory report of a patient who has been admitted to the hospital for a stab wound in the abdomen. Which finding is likely to be seen in the report?

Leukocytosis Leukocytosis results from an increase in the release of white blood cells (WBCs) from the bone marrow as a result of inflammation as a response to the stab wound.

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?

Maturation phase 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.

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?

Neutrophils phagocytize bacteria and damaged cells. Neutrophils are responsible for phagocytosis of bacteria and damaged cells at the site of injury. They are therefore first to arrive at the site.

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.

Obesity Diabetes mellitus Long-term use of corticosteroid medication 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.

The nurse is caring for a patient who is receiving negative-pressure wound therapy (NPWT). Which parameters does the nurse monitor? Select all that apply.

Platelet count Prothrombin time (PT) Partial prothrombin time (PPT) NPWT creates negative pressure in the wound bed and pulls excess fluid from the wound, reducing bacterial load and encouraging blood flow to the wound bed. The nurse should monitor the patient's serum protein levels and fluid and electrolyte balance because of losses from the wound. The nurse should also monitor the patient's coagulation studies (platelet count, PT, and PTT).

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?

Positions the patient the same way for each image

During a follow-up visit, a patient tells the nurse, "I had abdominal surgery seven days ago. The wound now is draining thick white material, and it smells bad." The nurse verifies the wound assessment and uses which term to document the drainage?

Purulent Purulent drainage consists of white blood cells, microorganisms, and other debris that signal an infection

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?

Reposition the patient every hour 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 patients may need to be turned and repositioned every hour, while others at lower risk may need to be turned and repositioned only every three to four hours.

The nurse examines a patient's pressure ulcer. Assessment findings include: subcutaneous fat is visible; bones, muscle, and tendon are not visible; slough is present; and tunneling is present. From this observation, which stage of the ulcer does the nurse document?

Stage 3 There are four stages of pressure ulcers. In stage 3, subcutaneous fat is visible in the ulcer, but bones, muscle, and tendon are not visible. The slough is present, and there is tunneling of the ulcer. In stage 2, the wound bed appears red to pink and the slough is absent. In stage 4, bone, muscle, and tendon are exposed. In an unstageable ulcer, the base of the ulcer is covered with slough and the true depth of the ulcer cannot be determined unless the slough is removed.

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?

Tertiary intention 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.