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
- hemostasis
Answer
- 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
- / 3
Answer area of intact skin with nonblanchable redness of localized area usually over bony prominence;