BSN 206 Hallmark questions and answers.Buy Quality Materials!
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Course
BSN 206
Institution
BSN 206
BSN 206 Hallmark questions and answers.Buy Quality Materials!
Steroids
Reduce inflammatory response and slow collagen synthesis
Cortisone
Depresses fibroblast activity and capillary growth
Chemotherapy
Depresses bone marrow production of white blood cells and impairs immune function
Tiss...
BSN 206 Hallmark questions and answers.Buy
Quality Materials!
Steroids
Reduce inflammatory response and slow collagen synthesis
Cortisone
Depresses fibroblast activity and capillary growth
Chemotherapy
Depresses bone marrow production of white blood cells and impairs immune function
Tissue repair is negatively influenced when..
hematocrit value is below 33% and hemoglobin value below 10g/100mL
Acute wound
- trauma from sharp object
- easily cleaned and repaired
- wound edges cleaned and intact
Chronic wound
- injuries
- Exposure to pressure, friction, and moisture impairs healing
Healing by tertiary intention can also be called..
Delayed primary intention or closure
- when sx wounds are not closed immediately but left open 3-5 days to allow edema or
infection to diminish
Identify wounds that would heal with secondary intention (select all):
a. pressure injury
b. surgical incision closed with staples
c. an open surgical wound requiring packing
d. full thickness burn
a. Pressure injury
c. an open surgical would requiring packing
d. full thickness burn
Which are examples of a chronic wound? (select all)
a. surgical incision
b. abrasion from a motor vehicle accident
c. stab wound
d. peripheral vascular venous stasis injury
e. pressure injury
d. peripheral vascular venous stasis injury
e. pressure injury
Primary healing
Healing over an injury that is evenly closed (incision). Edges are held in close
approximation; little granulation tissue formed.
Secondary healing
, Wounds left open and allowed to heal by scar formation. Their is tissue loss and open
wound edges.
Tertiary healing
Wounds intentially left open for 3-5 days to allow edema or/and infection to resolve or
drain & are then closed w/ sutures or staples (aka delayed primary healing)
Primary intention wound assessment:
1. Asses location of wound on body
2. Note wound margins. Approximated or closed together?
3. Observe drainage
4. Look for evidence of infection
5. Palpate along edges to feel healing ridge.
Secondary intention wound assessment:
1. Assess anatomical location
2. Assess wound deminsions (length, width and depth)
3. Assess for undermining
4. Assess extent of tissue loss (determine deepest viable
tissue layer in wound bed and determine stage)
5. observe tissue type
6. presence of exudate
7. Note is wound edges are rounded toward wound bed
Dehiscence
- partial or total separation of wound layers
- Occurs before collagen formation beings (3-11 days after surgery)
- wound is now to heal by secondary intention
Evisceration
wound separation with protrusion of organs
- emergency that requires surgical repair
- sterile gauze soaked in sterile saline must be placed over to prevent infection or skin
dryness
Fistula
abnormal passageway between two organs or between an internal organ and the body
surface
Common sites for pressure injuries:
- Sacrum -Coccyx -Ischial tuberosities -Greater trochanters -Heels -Scapula -Iliac crest -
Lateral and medial malleoli
Sheer stress
Force per unit area exerted parallel to the plane of interest
- Skin tears
- Shearing of epidermal layer from dermal layer (inappropriate tape removal)
Shear strain
Distortion or defamation of tissue as a result of sheer stress
- Subcutaneous tissue shears against dermal layer distorting the blood vessel (Pt. slides
down in bed)
Braden scale
sensory perception, moisture, activity, mobility, nutrition, friction and shear
4-23, <17 high risk for pressure injury
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