NU 136, Galen College of Nursing,
Exam 2, Units 4-6, Chapters 22, 28, 39,
29, 30, 38 with 557 detailed solutions.
NU 136, Galen College of Nursing,
Exam 2, Units 4-6, Chapters 22, 28, 39,
29, 30, 38 with 557 detailed solutions.
What are the locations for arterial ulcers - ANSWER -between toes
-tips of toes
-over phalangeal heads
-around lateral malleolus
what are the characteristics of arterial ulcers - ANSWER -severe pain
-minimal drainage
-decreased temperature
-absent or diminished pulses
-cyanosis
-thickened toenails
-gangrene
what are the locations for venous ulcers - ANSWER -medial lower leg
-ankle
-superior to medial melleolus
-seldom, if ever noted on the foot or above the knee
what are the characteristics of venous ulcers - ANSWER -moderate to large amount of drainage
-pain levels vary
-ankle flare
,NU 136, Galen College of Nursing,
Exam 2, Units 4-6, Chapters 22, 28, 39,
29, 30, 38 with 557 detailed solutions.
-lipodermatosclerosis (hard fibrous of surrounding tissue)
-dialated superficial veins
what are the location for neuropathic (Diabetic) ulcers - ANSWER -plantar aspect of foot
-over metatarsal heads
-under heel
what are the characteristics for neuropathic ulcers - ANSWER -low to moderate drainage
-foot deformities
-deminished or absent sensation in foot
-palpable pulses
-osteomyelitis
-usually painless
what are the phases of wound healing - ANSWER hemostatis
inflammation
proliferation
maturation
what phase is the hemostasis - ANSWER phase 1 -the immediate response the body initiates to heal
(blood clotting)
what phase is the inflammation - ANSWER phase 2 - begins immediately and last 4-5 days, it is the
protective response (heat, pain, edema) wbc & macrophages migrate to the wound & begin the repair
what phase is the proliferation - ANSWER phase 3 - reconstructive phase - begins on 3rd or 4th day and
lasts 2-3 weeks
,NU 136, Galen College of Nursing,
Exam 2, Units 4-6, Chapters 22, 28, 39,
29, 30, 38 with 557 detailed solutions.
what phase is the maturation phase - ANSWER phase 4 - final phase/remodeling phase - scar
maturation, scar slowly thins and becomes paler - begins about 3 weeks after injury and can last up to 2
years
what factors affect wound healing - ANSWER -age
-nutrition (protein/fluid needed for healing)
-medications (heparin, steroids, antineoplastics interfere
w/healing
-Infection (slows healing) chronic illness (COPD, DM, CV)
slows wound healing due to lack of oxygen & nutrients at
the cellular level
-lifestyle (regular exercise)
-decreased immune system
-decreased liver function
what is first intention (Primary) - ANSWER little tissue loss - edges of wound approximate and only a
slight chance of infection
what is second intention - ANSWER a wound with tissue loss - edges of wound do not
approximate;wound left open & fills with scar tissue
what is third intention (Tertiary) - ANSWER occurs when there is delayed suturing of a wound/wound
sutured after granulation tissue begins to form. (Healing.)
what are the closed wounds and characteristics - ANSWER -contusion (bruise w/out breaking skin)
-hematoma (pooling of blood under unbroken skin)
-sprain (twisting of a joint)
, NU 136, Galen College of Nursing,
Exam 2, Units 4-6, Chapters 22, 28, 39,
29, 30, 38 with 557 detailed solutions.
what are the open wounds and characteristics - ANSWER -incision (surgically made separation of tissues
w/clean
even edges)
-laceration (traumatic separation of tissue)
-abrasion (traumatic scraping)
-penetrating (bullet/metal)
-avulsion (tearing away)
-ulceration (excavation of skin
-perforation (internal organ/cavity)
-crush (tissue disrupted or compressed
list complications of wound healing - ANSWER -hemorrhage (uncontrolled bleeding)
-dehiscence (spontaneous opening of an incision)
-evisceration (protrusion of an internal organ through an
incision)
-infection (redness, edema, pain, purulent drainage)
what is the purpose of wound drains - ANSWER to provide an exit for blood & pus that accumulate
during the inflammation process
how does an active drain work - ANSWER it is attached to a wound suction device to remove any
accumulated exudate or other material
(ex. Hemovac & Jackson-Pratt)
how does a passive drain work - ANSWER it has no suction device, it works by the increased pressure
inside the wound & depends on gravity & capillary action to pull out any fluid buildup (Penrose)
Exam 2, Units 4-6, Chapters 22, 28, 39,
29, 30, 38 with 557 detailed solutions.
NU 136, Galen College of Nursing,
Exam 2, Units 4-6, Chapters 22, 28, 39,
29, 30, 38 with 557 detailed solutions.
What are the locations for arterial ulcers - ANSWER -between toes
-tips of toes
-over phalangeal heads
-around lateral malleolus
what are the characteristics of arterial ulcers - ANSWER -severe pain
-minimal drainage
-decreased temperature
-absent or diminished pulses
-cyanosis
-thickened toenails
-gangrene
what are the locations for venous ulcers - ANSWER -medial lower leg
-ankle
-superior to medial melleolus
-seldom, if ever noted on the foot or above the knee
what are the characteristics of venous ulcers - ANSWER -moderate to large amount of drainage
-pain levels vary
-ankle flare
,NU 136, Galen College of Nursing,
Exam 2, Units 4-6, Chapters 22, 28, 39,
29, 30, 38 with 557 detailed solutions.
-lipodermatosclerosis (hard fibrous of surrounding tissue)
-dialated superficial veins
what are the location for neuropathic (Diabetic) ulcers - ANSWER -plantar aspect of foot
-over metatarsal heads
-under heel
what are the characteristics for neuropathic ulcers - ANSWER -low to moderate drainage
-foot deformities
-deminished or absent sensation in foot
-palpable pulses
-osteomyelitis
-usually painless
what are the phases of wound healing - ANSWER hemostatis
inflammation
proliferation
maturation
what phase is the hemostasis - ANSWER phase 1 -the immediate response the body initiates to heal
(blood clotting)
what phase is the inflammation - ANSWER phase 2 - begins immediately and last 4-5 days, it is the
protective response (heat, pain, edema) wbc & macrophages migrate to the wound & begin the repair
what phase is the proliferation - ANSWER phase 3 - reconstructive phase - begins on 3rd or 4th day and
lasts 2-3 weeks
,NU 136, Galen College of Nursing,
Exam 2, Units 4-6, Chapters 22, 28, 39,
29, 30, 38 with 557 detailed solutions.
what phase is the maturation phase - ANSWER phase 4 - final phase/remodeling phase - scar
maturation, scar slowly thins and becomes paler - begins about 3 weeks after injury and can last up to 2
years
what factors affect wound healing - ANSWER -age
-nutrition (protein/fluid needed for healing)
-medications (heparin, steroids, antineoplastics interfere
w/healing
-Infection (slows healing) chronic illness (COPD, DM, CV)
slows wound healing due to lack of oxygen & nutrients at
the cellular level
-lifestyle (regular exercise)
-decreased immune system
-decreased liver function
what is first intention (Primary) - ANSWER little tissue loss - edges of wound approximate and only a
slight chance of infection
what is second intention - ANSWER a wound with tissue loss - edges of wound do not
approximate;wound left open & fills with scar tissue
what is third intention (Tertiary) - ANSWER occurs when there is delayed suturing of a wound/wound
sutured after granulation tissue begins to form. (Healing.)
what are the closed wounds and characteristics - ANSWER -contusion (bruise w/out breaking skin)
-hematoma (pooling of blood under unbroken skin)
-sprain (twisting of a joint)
, NU 136, Galen College of Nursing,
Exam 2, Units 4-6, Chapters 22, 28, 39,
29, 30, 38 with 557 detailed solutions.
what are the open wounds and characteristics - ANSWER -incision (surgically made separation of tissues
w/clean
even edges)
-laceration (traumatic separation of tissue)
-abrasion (traumatic scraping)
-penetrating (bullet/metal)
-avulsion (tearing away)
-ulceration (excavation of skin
-perforation (internal organ/cavity)
-crush (tissue disrupted or compressed
list complications of wound healing - ANSWER -hemorrhage (uncontrolled bleeding)
-dehiscence (spontaneous opening of an incision)
-evisceration (protrusion of an internal organ through an
incision)
-infection (redness, edema, pain, purulent drainage)
what is the purpose of wound drains - ANSWER to provide an exit for blood & pus that accumulate
during the inflammation process
how does an active drain work - ANSWER it is attached to a wound suction device to remove any
accumulated exudate or other material
(ex. Hemovac & Jackson-Pratt)
how does a passive drain work - ANSWER it has no suction device, it works by the increased pressure
inside the wound & depends on gravity & capillary action to pull out any fluid buildup (Penrose)
