The nurse is caring for a patient with a wound healing by ...

[maegan_martin]

The nurse is caring for a patient with a wound healing by full-thickness repair. Which phases will the nurse monitor for in this patient? (Select all that apply.)
 
  a. Hemostasis
  b. Maturation
  c. Inflammatory
  d. Proliferative
  e. Reproduction
  f. Reestablishment of epidermal layers

Question 2

The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment? (Select all that apply.)
 
  a. Vision
  b. Hyperemia
  c. Induration
  d. Blanching
  e. Temperature of skin

[Chocorrol77]

Answer to Question 1

ANS: A, B, C, D
The four phases involved in the healing process of a full-thickness wound are hemostasis, inflammatory, proliferative, and maturation. Three components are involved in the healing process of a partial-thickness wound: inflammatory response, epithelial proliferation (reproduction) and migration, and reestablishment of the epidermal layers.

Answer to Question 2

ANS: B, C, D, E
Assessment of the skin includes both visual and tactile inspection. Assess for hyperemia and palpate for blanching or nonblaching. Early signs of skin damage include induration, bogginess (less-than-normal stiffness), and increased warmth at the injury site compared to nearby areas. Changes in temperature can indicate changes in blood flow to that area of the skin. Vision is not included in the skin assessment.

[maegan_martin]

Gracias!

[jomama]

TYSM