NUR 2206 Midterm 2 - 2. chronic wound Answer do not heal as expected...

NUR 2206 Midterm 2

• acute wound

Answer heals quickly, edges approximated, low risk of infection

• chronic wound

Answer do not heal as expected, remain in inflammatory phase

--> could be due to arterial or venous insufficiency

• phases of wound healing

Answer

• hemostasis

• inflammatory phase
• proliferation phase
• materation phase

• inflammatory phase

Answer 4-6 days; phagocytosis and WBC, generalized body response to hemostasis, growth factor released

-acute inflammation (pain, heat, redness, swelling)

• proliferation phase

Answer lasts several weeks;

granulation tissue develops to fill in wounds; fibroblastic, regenerative, connective tissue -new blood cell formation -oxygen and nutrients needed to heal 1 / 3

• maturation phase

Answer begins ~ day 21;

can last months of years; *collagen* remodeled; blood vessels compressed -scar

• primary intention

Answer wound edges well approximated

• secondary intention

Answer wound edge not well approximated; heals by granulation tissue formation

• tertiary intention

Answer delayed primary intention

• desiccation

Answer drying up of wound; cells die and rust over wound site

• maceration

Answer overhydration of cells due to moisture somewhere on skin;

--> leads to softening and breakdown of skin

• dehiscence

Answer partial or total separation of wound layers due to excessive stress on wounds that are not healed;

sutures holding wound together pop --> pts. with a lot of fat, diabetic, or elderly 2 / 3

--> cannot be closed the same way due to bacteria

• evisceration

Answer complete separation of wound with protrusion of viscera through incision (intestines/organs coming out that happens 2-7 days after surgery)

• fistula

Answer abnormal passage from internal organ to outside the body or from one internal organ to another

--> skin doesnt heal well or suture slips --> caused by abscess

• granulation tissue

Answer During a dressing change, inspection of the wound reveals what appears to be reddish-pink tissue in the wound. The nurse interprets this as most likely indicating

• area of maceration

Answer A patient has a wound caused by exposure to moisture. This wound is considered to be

• ischemia

Answer paleness in area where pressure was applied; deficiency of blood in a particular area

• reactive hyperemia

Answer blanchable reddening of the skin when pressure is re- moved

• stage 1 pressure ulcer

Answer area of intact skin with nonblanchable redness of localized area usually over bony prominence;

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