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1. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in the wound care procedure. Which of the following findings indicate wound healing.
a Erythema on the skin surrounding a client's wound
b. Deep red color on the center of the clients wound
Inflammation noted on the tissue edges of a client's wound
d. Increase in serosanguineous exudate from the clients wound (damaged capillaries)
Rationale: Leadership 7.0 pg 329:
• Stages of Wound Healing
• Inflammatory stage-beginning stage, also usually suggests infection
Begins with the injury and lasts 3 to 6 days
Effects to the wound: controlling bleeding with vasoconstriction and retraction of blood vessels, and with clot formation.
Delivering oxygen, WBCs, nutrients to the area via blood supply. Hemostasis occurs along with fibrin formation. Macrophages engulf microorganisms and cellular debris (phagocytosis).
• Proliferative stage
Lasts the next 3 to 24 days
Effects to the wound: replacing lost tissue with connective or granulated tissue or collagen. Contracting the wound's edges. Resurfacing of new epithelial cells. Healthy granulation tissue does not bleed easily. Dark granulation tissue can be a sign of
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