Wounds Flashcards
The nurse is caring for a client with a stage II pressure ulcer. The nurse knows that this means which of the following?
A. Full thickness skin loss through the dermis
B. Full thickness skin loss exposing subcutaneous tissue
C. Partial thickness skin loss
D. Non-blanchable erythema only
C. Partial thickness skin loss
The nurse is caring for several bedridden clients during a shift. To assess risk for skin breakdown, the nurse knows that the Braden scale must be assessed and charted for each
client how often?
A. Once every 24 hours
B. Once per shift
C. Every four hours
D. On admission only
B. Once per shift
A nurse is educating a client with a Stage I pressure ulcer on the coccyx, as well as the client’s spouse. Which statement by the spouse indicates the need for further education?
A. “I will turn her every 1-2 hours to avoid more pressure on that area.”
B. “I’ll wipe off any urine or stool as soon as possible.”
C. “If I see any open areas, I’ll call the home health nurse.”
D. “I will rub her tailbone a few times a day to help with the pain.”
D. “I will rub her tailbone a few times a day to help with the pain.”
A nurse is caring for an immobile client with a Braden score of 11. What is the nurse’s priority intervention based on this score?
A. Keep the client from getting hypothermia
B. Turn the client frequently
C. Give the client protein shakes daily
D. Put heating pads on suspicious areas
B. Turn the client frequently
First intention wound healing
An open wound is closed surgically with sutures or staples as soon as possible
Second intention wound healing
A wound is kept clean but otherwise left alone to let the tissue repair itself, allowing the wound to close on its own.
Third intention wound healing
The wound is left open for a period of time to make sure no infection will occur, then it is closed surgically with sutures or staples
Wound healing process phases
Hemostasis
Inflammation
Proliferation
Maturation
Hemostasis
Occurs immediately after initial injury.
Involved blood vessels constrict and blood clotting begins.
Exudate is formed, causing swelling and pain.
Increased perfusion results in heat and redness.
Platelets stimulate other cells to migrate to the injury to participate in other phases of healing.
Inflammation Phase
Follows hemostasis and lasts about 2 to 3 days
White blood cells, predominantly leukocytes and macrophages, move to the wound.
Macrophages enter the wound area and remain for an extended period.
They ingest debris and release growth factors that attract fibroblasts to fill in the wound.
The patient has a generalized body response
Proliferation Phase
Lasts for several weeks.
New tissue is built to fill the wound space through the action of fibroblasts.
Capillaries grow across the wound.
A thin layer of epithelial cells forms across the wound.
Granulation tissue forms a foundation for scar tissue development
Maturation Phase
Final stage of healing; begins about 3 weeks after the injury, possibly continuing for months or years.
Collagen is remodeled.
New collagen tissue is deposited.
Scar becomes a flat, thin, white line.
Stages of pressure injuries
STAGE 1
Stage 1: non-blanchable erythema of intact skin
Stages of pressure injuries
STAGE 2
Stage 2: partial-thickness skin loss with exposed dermis
Stages of pressure injuries
STAGE 3
Stage 3: full-thickness skin loss; not involving underlying fascia
