Chapter 55 Wound Healing

Question 1

Primary intention

Answer 1

Little to no tissue loss
Edges approximated (with surgical incision)
Heals rapidly
Low risk of infection and minimal scarring
(Ex: Closed surgical incision w/staples)

Question 2

Secondary intention

Answer 2

Loss of tissue
Wound edges widely separated,unapproximated (pressure or proper burn)
Increase risk of infection
Longer healing time (granulation) and scarring

Question 3

Tertiary Intention

Answer 3

Deep
Widely separated
Closure of wounds when free of infection and edema
Spontaneous opening of a previous closed wound

Question 4

Stages of wound healing

Answer 4

Inflammation
Proliferative
Maturation/remodeling

Question 5

Eschar

Answer 5

Black and hinders healing and seeing stage of healing

Question 6

Serous drainage

Answer 6

The portion of the blood (serum) that is watery and clear or slightly yellow in appearance (fluid in blisters)

Question 7

Sanguineous drainage

Answer 7

Contains serum and red blood cells,thick and appears reddish

Question 8

Serosanguineous drainage

Answer 8

Contains both blood and serum

Watery and looks pale and pink bc of misguide of red and clear fluid

Question 9

Purosanguineous

Answer 9

A mixed drainage of pus and blood (newly injected wound)

Question 10

Purulent drainage

Answer 10

The result of infection

Thick and contains wbc, tissue debris, and bacteria

Question 11

Albumin levels

Answer 11

3.5 - 5.5 g

Question 12

Dehiscence

Answer 12

A partial or goal rupture (separation) of sutured wound

Question 13

Evisceration

Answer 13

A a dehiscence that involves the protrusion of visceral organs through a wound healing

Question 14

Prevention of dehiscence and evisceration

Answer 14

Fold folded blanket or small pillow over surgical wounds when client coughs to support wound

Question 15

Hemorrhage

Answer 15

Escape of blood drop ruptured blood vessel, slipped suture, clot dislodgment

Question 16

Stage 1 pressure injury

Answer 16

Nonblanchable erythema of intact skin

Swollen tissue and wound coloring differs from surrounding site

Question 17

Stage 2 pressure injury

Answer 17

Partial thickness skin loss with exposed dermis -w/out slough, eschar, granulation, adipose tissues
Can appear as an intact or ruptured blister

Question 18

Stage 3 pressure injury

Answer 18

Full thickness skin loss
Visible adipose tissue w/possible granulation tissue
Some slough/eschar present
No exposed muscle; tendons, ligaments, cartilage, bone
Possible tumbling and undermining

Question 19

Stage 4 pressure injury

Answer 19

Full thickness skins be tissue loss

Skin, tissue, cartilage, bone, fascia, muscle, ligaments, and tendons exposed or early palpable

Question 20

Hemoglobin normal range

Answer 20

14-19 gm /dL for male

12-16 for female

Question 21

Normal BMI

Answer 21

18.5-25