MODULE 3 CH. 12, 14, 15 Emotion- Comfort-Anxiety- Depression-Immobility-Skin Integrity
Chapter 12 Notes:
Healing:
Regeneration: is the replacement of lost cells/tissues with cells of the same type
Repair: a more common type of healing that results in scar formation, by primary, secondary, and tertiary
intention
o Primary intention: wound margins are neatly approximated like surgical incision or paper cut
(initial, granulation, and maturation) incision w/blood clot-edges approximated w/suture, fine
scar—3-5 days clot serves as a meshwork for starting capillary growth
o Secondary intention: occur from trauma, injury, and infection; have large amounts of exudate
(fluid from a blood vessel) and its wide/irregular wound margins that have extensive tissue loss,
have edges that can’t be brought together—irregular/large wound w/blood clot-granulation
tissue fills in wound- large scar---4 days-4 weeks wound is fragile
o Tertiary Intention: have delayed suturing where 2 layers of granulation are sutured together---
contaminated wound-granulation tissue-delayed closure w/suture--- 7 days-several months
strengthen of scar
Wounds are classified by surgical/ nonsurgical, acute/chronic, and by the depth of tissue like superficial,
partial thickness, and full thickness
Nurses are to perform a thorough assessment of wounds upon admission and on a regular basis by
observing and recording characteristics
Wound management includes cleaning the wound to remove dirt/debris from the wound bed, treating
infections to prepare the wound for healing, and protecting the clean wound from trauma so it can heal
normally
Wound management and dressings depend on the causative agent, degree of injury, and patient condition
along with the type, extent, and characteristics if the wound and which phase of healing it is at
Adjunctive therapies may be used to aid in the healing process
Negative pressure wound therapy (vacuum-assisted wound closure) uses suction to remove drainage and
speed up the healing process
Hyperbaric 02 accelerates the granulation tissue formation and the healing process
Platelet-derived growth factor stimulates wound healing by promoting cell proliferation and migration
Nutritional measures promote wound healing such as a high fluid intake which is needed to replace fluid
loss perspiration and exudate formation, along with high protein, carb and vitamins w/moderate fat intake
are necessary to promote healing
Hand hygiene and aseptic techniques are important to keep the wound from infection
The pt./family needs to know how to perform dressing changes
Assist the pt. with coping with the changes that may come with scars
Pressure Injuries:
Pressure injuries are damage to the skin, underlying soft tissue over bony prominences or related to other
medical devices
The injury occurs because of intense and/or prolonged pressure or pressure in combination with shear.
The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition,
perfusion, co-morbidities, and condition of the soft tissue.
A pressure injury can have skin that is still intact or skin that is open and extremely painful
Always assess for pressure injury upon admission and at periodic intervals based on condition and care
and use a validated risk assessment
Adequate nutrition, pain management, control of medical conditions, and pressure relief along with local
care of the wound are all required for pt.
Local care may include debridement, wound cleaning, application of dressing, and relief of pressure
Adequate nutrition and identifying malnutrition is an important nursing responsibilities
Ensure you are also supporting the caregiver as well as the pt. through the added responsibility of
pressure injury treatment
, Chapter 12 NCLEX Questions
1. A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5°F temperature, slight redness at
the incision margins, and 30 mL serosanguinous drainage in the Jackson-Pratt drain. Based on this assessment,
what conclusion would the nurse make?
a. The patient has a normal inflammatory response.
b. The abdominal incision shows signs of an infection.
c. The abdominal incision shows signs of impending dehiscence.
d. The patient’s health care provider must be notified about their condition.
Rationale: The local response to inflammation includes the manifestations of redness, heat, pain, swelling, and loss
of function. Systemic manifestations of inflammation include an increased white blood cell (WBC) count with a shift
to the left, malaise, nausea and anorexia, increased pulse and respiratory rate, and fever.
2. The nurse assessing a patient with a chronic leg wound finds redness and edema. The patient reports pain at the
wound site. What would the nurse expect to be ordered to assess the patient’s systemic response?
a. Serum protein analysis
b. WBC count and differential
c. Punch biopsy of the center of the wound
d. Culture and sensitivity of the wound
Rationale: Neutrophils and monocytes move from the circulation to the site of injury. The bone marrow releases
more neutrophils into circulation, which results in elevation of the WBC count, especially the neutrophil count. If
the bone marrow releases immature forms of neutrophils (i.e., bands) into circulation, a shift to the left occurs.
Patients with acute bacterial infections have high WBC counts with a shift to the left.
3. A patient in the unit has a 103.7°F temperature. Which intervention would be most effective in restoring normal
body temperature?
a. Using a cooling blanket while the patient is febrile
b. Giving antipyretics on an around-the-clock schedule
c. Providing increased fluids and have the AP give sponge baths
d. Giving prescribed antibiotics and placing warm blankets for comfort
Rationale: Antipyretics are used to lower the body temperature and should be given around the clock to prevent
acute swings in temperature. Chills may be evoked or perpetuated by the intermittent administration of
antipyretics. These agents cause a sharp decrease in temperature. When an antipyretic wears off, the body may
initiate a compensatory involuntary muscular contraction (i.e., chill) to raise the body temperature up to its
previous level. This unpleasant side effect of antipyretic drugs can be prevented by giving the agents regularly and
at 2- to 4-hour intervals. Sponge baths and cooling blankets may not decrease the body temperature unless
antipyretic drugs have been given to lower the set point. Otherwise, the body will initiate compensatory
mechanisms (e.g., shivering) to restore body heat.
4. A nurse is caring for a patient who has a pressure injury that is treated with debridement, irrigations, and moist
gauze dressings. How would the nurse expect healing to occur?
a. Cell regeneration
b. Tertiary intention
c. Secondary intention
d. Remodeling of tissues
Rationale: A pressure injury can provoke an inflammatory reaction that results in large amounts of exudate and
wide, irregular wound margins with extensive tissue loss. Pressure injuries may have edges that cannot be
approximated. This type of wound heals by secondary intention. The healing and granulation take place from the
edges inward and from the bottom of the wound upward until the defect is filled. Granulation tissue develops, and
a large scar results.
5. Which patient has the greatest risk for delayed wound healing?
Chapter 12 Notes:
Healing:
Regeneration: is the replacement of lost cells/tissues with cells of the same type
Repair: a more common type of healing that results in scar formation, by primary, secondary, and tertiary
intention
o Primary intention: wound margins are neatly approximated like surgical incision or paper cut
(initial, granulation, and maturation) incision w/blood clot-edges approximated w/suture, fine
scar—3-5 days clot serves as a meshwork for starting capillary growth
o Secondary intention: occur from trauma, injury, and infection; have large amounts of exudate
(fluid from a blood vessel) and its wide/irregular wound margins that have extensive tissue loss,
have edges that can’t be brought together—irregular/large wound w/blood clot-granulation
tissue fills in wound- large scar---4 days-4 weeks wound is fragile
o Tertiary Intention: have delayed suturing where 2 layers of granulation are sutured together---
contaminated wound-granulation tissue-delayed closure w/suture--- 7 days-several months
strengthen of scar
Wounds are classified by surgical/ nonsurgical, acute/chronic, and by the depth of tissue like superficial,
partial thickness, and full thickness
Nurses are to perform a thorough assessment of wounds upon admission and on a regular basis by
observing and recording characteristics
Wound management includes cleaning the wound to remove dirt/debris from the wound bed, treating
infections to prepare the wound for healing, and protecting the clean wound from trauma so it can heal
normally
Wound management and dressings depend on the causative agent, degree of injury, and patient condition
along with the type, extent, and characteristics if the wound and which phase of healing it is at
Adjunctive therapies may be used to aid in the healing process
Negative pressure wound therapy (vacuum-assisted wound closure) uses suction to remove drainage and
speed up the healing process
Hyperbaric 02 accelerates the granulation tissue formation and the healing process
Platelet-derived growth factor stimulates wound healing by promoting cell proliferation and migration
Nutritional measures promote wound healing such as a high fluid intake which is needed to replace fluid
loss perspiration and exudate formation, along with high protein, carb and vitamins w/moderate fat intake
are necessary to promote healing
Hand hygiene and aseptic techniques are important to keep the wound from infection
The pt./family needs to know how to perform dressing changes
Assist the pt. with coping with the changes that may come with scars
Pressure Injuries:
Pressure injuries are damage to the skin, underlying soft tissue over bony prominences or related to other
medical devices
The injury occurs because of intense and/or prolonged pressure or pressure in combination with shear.
The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition,
perfusion, co-morbidities, and condition of the soft tissue.
A pressure injury can have skin that is still intact or skin that is open and extremely painful
Always assess for pressure injury upon admission and at periodic intervals based on condition and care
and use a validated risk assessment
Adequate nutrition, pain management, control of medical conditions, and pressure relief along with local
care of the wound are all required for pt.
Local care may include debridement, wound cleaning, application of dressing, and relief of pressure
Adequate nutrition and identifying malnutrition is an important nursing responsibilities
Ensure you are also supporting the caregiver as well as the pt. through the added responsibility of
pressure injury treatment
, Chapter 12 NCLEX Questions
1. A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5°F temperature, slight redness at
the incision margins, and 30 mL serosanguinous drainage in the Jackson-Pratt drain. Based on this assessment,
what conclusion would the nurse make?
a. The patient has a normal inflammatory response.
b. The abdominal incision shows signs of an infection.
c. The abdominal incision shows signs of impending dehiscence.
d. The patient’s health care provider must be notified about their condition.
Rationale: The local response to inflammation includes the manifestations of redness, heat, pain, swelling, and loss
of function. Systemic manifestations of inflammation include an increased white blood cell (WBC) count with a shift
to the left, malaise, nausea and anorexia, increased pulse and respiratory rate, and fever.
2. The nurse assessing a patient with a chronic leg wound finds redness and edema. The patient reports pain at the
wound site. What would the nurse expect to be ordered to assess the patient’s systemic response?
a. Serum protein analysis
b. WBC count and differential
c. Punch biopsy of the center of the wound
d. Culture and sensitivity of the wound
Rationale: Neutrophils and monocytes move from the circulation to the site of injury. The bone marrow releases
more neutrophils into circulation, which results in elevation of the WBC count, especially the neutrophil count. If
the bone marrow releases immature forms of neutrophils (i.e., bands) into circulation, a shift to the left occurs.
Patients with acute bacterial infections have high WBC counts with a shift to the left.
3. A patient in the unit has a 103.7°F temperature. Which intervention would be most effective in restoring normal
body temperature?
a. Using a cooling blanket while the patient is febrile
b. Giving antipyretics on an around-the-clock schedule
c. Providing increased fluids and have the AP give sponge baths
d. Giving prescribed antibiotics and placing warm blankets for comfort
Rationale: Antipyretics are used to lower the body temperature and should be given around the clock to prevent
acute swings in temperature. Chills may be evoked or perpetuated by the intermittent administration of
antipyretics. These agents cause a sharp decrease in temperature. When an antipyretic wears off, the body may
initiate a compensatory involuntary muscular contraction (i.e., chill) to raise the body temperature up to its
previous level. This unpleasant side effect of antipyretic drugs can be prevented by giving the agents regularly and
at 2- to 4-hour intervals. Sponge baths and cooling blankets may not decrease the body temperature unless
antipyretic drugs have been given to lower the set point. Otherwise, the body will initiate compensatory
mechanisms (e.g., shivering) to restore body heat.
4. A nurse is caring for a patient who has a pressure injury that is treated with debridement, irrigations, and moist
gauze dressings. How would the nurse expect healing to occur?
a. Cell regeneration
b. Tertiary intention
c. Secondary intention
d. Remodeling of tissues
Rationale: A pressure injury can provoke an inflammatory reaction that results in large amounts of exudate and
wide, irregular wound margins with extensive tissue loss. Pressure injuries may have edges that cannot be
approximated. This type of wound heals by secondary intention. The healing and granulation take place from the
edges inward and from the bottom of the wound upward until the defect is filled. Granulation tissue develops, and
a large scar results.
5. Which patient has the greatest risk for delayed wound healing?
