Author Question: The nurse is assessing the pressure ulcer of a 68-year-old female client. Which of the following ... (Read 66 times)

bobbysung · **on:** Jul 23, 2018

The nurse is assessing the pressure ulcer of a 68-year-old female client. Which of the following would indicate to the nurse that healing is taking place?

1. Eschar
2. Slough
3. Granulation tissue
4. Exudate

Question 2

The 23-year-old female client is concerned about scarring from her hernia surgery. She had a third-degree burn on her right arm when she was younger that left a scar that she is self-conscious about.

Then nurse explains to the client that the wound from the burn healed differently than the surgi-cal incision will heal. The incision that she will have will heal by:
1. Primary intention
2. Secondary intention
3. Tertiary intention
4. Dehiscence

Mollythedog · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: 3
Granulation tissue is red moist tissue composed of new blood vessels, the presence of which in-dicates progression toward healing. Black or brown necrotic tissue is eschar which you will need to remove before healing can proceed. Soft, yellow or white tissue is characteristic of slough (stringy substance attached to wound bed), and you will need to remove this before the wound is able to heal. Wound exudate describes the amount, color, consistency, and odor of wound drainage and is part of the wound assessment. Excessive exudate indicates the presence of infec-tion. The presence of exudate on the skin surrounding the wound is indicative of wound deterio-ration.

Answer to Question 2

ANS: 1
The surgical wound heals by primary intention. The skin edges are approximated, or closed, and the risk for infection is low. Healing occurs quickly; with minimal scar formation, as long as in-fection and secondary breakdown is prevented. Healing occurs by epithelialization. A wound involving loss of tissue, such as a burn, pressure ulcer, or severe laceration, heals by secondary intention. The wound is left open until it becomes filled by scar tissue. It takes longer for a wound to heal by secondary intention, and thus the chance of infection is greater. In tertiary in-tention, a wound is left open for several days, then wound edges are approximated. This type of healing is for wounds that are contaminated and require observation for signs of inflammation. Closure of wound is delayed until risk for infection is resolved. When a wound fails to heal properly, the layers of skin and tissue separate. This most commonly occurs before collagen for-mation (3 to 11 days after injury). Dehiscence is the partial or total separation of wound layers.