GALEN COLLEGE OF NURSING NUR 155 EXAM 3
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What are bony prominences? - Precise Answer ✔✔They are the end or a
protrusion of bone where skin , muscle, and tissue is thin. They are the
highest risk areas of the body for developing pressure sores.
Full thickness injury - Precise Answer ✔✔An injury extending through
the subcutaneous skin layers, muscles, and down to the bone
What is blanching? - Precise Answer ✔✔It's whitening of the skin when
pressure is applied. The result is brief temporary loss of blood flow.
Note} pressure injuries and ulcers are non-blanchable.
What is a Partial thickness injury ? - Precise Answer ✔✔It's an injury to
layers of the skin including the subcutaneous, dermis, and , epidermis.
Note Partial thickness wounds are associated with stage 2 pressure
injuries/ ulcers
,What is debridement? - Precise Answer ✔✔Within woundcare,
debridement refers to the removal of adherent, dead or contaminated
tissue from the wound.
serous drainage - Precise Answer ✔✔clear, watery
Made from plasma
Healing wounds
purulent drainage - Precise Answer ✔✔Thick, yellow, green, tan, or
brown drainage
In infected wounds
sanguineous drainage - Precise Answer ✔✔Pink or pale red
Mix of serous and red blood fluid
Occurs in fresh wounds
serosanguineous drainage - Precise Answer ✔✔Bright red mostly blood
Sign of healing
,Indicates bleeding
R.E.E.D.A.N - Precise Answer ✔✔Redness
Ecchymosis / bruise
Edema
Drainage
Approximation
Number of staples or sutures
Inflammatory stage of wound healing - Precise Answer ✔✔lasts for
about 3 days. phagocytosis of body works to clean the wound
Bleeding occurs which triggers coagulation cascade and the formation of
a clot to stop bleeding
Cytokines are released in this stage
, Increase of pain, redness, warmth, and swelling in the injured area as the
blood vessels dilate and leak fluid to the tissue surrounding a injury .
Macrophages and neutrophils are drawn to the site of the injury and
begin to process of cleaning the wound of bacteria and debris.
At the end of the phase the wound bed is clean and ready to begin the
actual healing process
Proliferate healing stage - Precise Answer ✔✔Last several weeks but
can be shorter with surgically closed wounds
Granulation tissue develops in this stage
Involves the development of new blood vessels also called Angiogenesis
The key cell in this stage are fibroblasts which produce growth factors ,
synthesize the collagen and proteins needed to form granulation tissue ,
promote angiogenesis
granulation tissue - Precise Answer ✔✔Beefy red in appearance
Bleeds easily
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