lecture two--wounds and pressure ulcers

Question 1

steps in the inflammatory response

Answer 1

vascular response
cellular response
formation of exudate
healing

Question 2

inflammatory phase

Answer 2

acute: 2/3 weeks, lots of neutrophils
sub acute: longer
chronic: long, has lymphocytes

Question 3

what can heal itself vs. what can’t heal itself

Answer 3

liver, bone, kidney, pancreas all regrow

neurons CAN’T regrow, they are replaced by glial cells or stem cells
skeletal and cardiac muscles are replaced with scar tissue

Question 4

repair vs. regeneration

Answer 4

repair: healing as a result of lost cells being replaced with connective tissue.
more common than regeneration

Question 5

PRIMARY INTENTION

Answer 5

appearance: edges approximated/aligned , fine scar, the wound is pink and vascular, and the epithelial surface regenerates
time: lasts 3-5 days
normal sx/sx: redness and swelling is normal at this stage of wound healing

granulation: 5 days to 3 weeks, fibroblasts go to the site.

Question 6

SECONDARY INTENTION

Answer 6

irregular, large wound, granulation tissue fills in wound, large scar
EDGES NOT CLOSED/UNAPPROXIMATED
These wounds are those that occur from trauma, ulceration, or infection, with large amounts of exudate, wide/irregular margins, and extensive tissue loss.

Question 7

tertiary intention

Answer 7

edges are only closed because they were sutured shut, it is really primary intention that needed a little help/takes longer.

corticosteroids can delay wound healing here because of a weakened immune system.

Question 8

PRESSURE ULCERS

Answer 8

graded and stages according to deepest level of tissue damage.
slough and eschar must be removed for accurate staging

stage 1: skin INTACT, areas of non-blanchable redness (in dark skinned patients, look for an area that is darker)
stage 2: broken skin, partial thickness loss, shallow open ulcers with a red/pink, wound bed, presents as a intact or serum filled blister
stage 3: full thickness skin loss, deep crater, undermining in the wound itself
stage 4: full thickness skin loss extending to muscle or bone, tunneling and undermining can be present.

Question 9

assessment and nursing diagnoses
documentation

Answer 9

document skin problems as soon as you see them, assess risk points particularly (elbows, hips, butt, etc.), but also assess all skin.

wound measurement: in cm, head to toe, side to side, depth

nursing diagnoses: impaired skin or tissue integrity, risk for delayed healing.

documentation: location, type (stage if pressure ulcer), measurements, undermining? tunneling? % granulation tissue, slough, eschar, drainage

Question 10

wound drainage assessment

Answer 10

assess amount of drainage in the drain
assess color of drainage
serous: clear
serosanguineous: gray with red tints
sanguineous: red
purulent: yellow/pus like–can indicate infection