Do you know that the skin is the largest organ of the body?.Yes the skin provide protection, fluid balance, sensation.It facilitate communication and how you see yourself as an individual.A wound is a disruption of a normal state of the body. Wound heal faster in healthy people with good nutrition,physical status with intentional. (surgical wound)Wound will heal by primary, secondary and tertiary intention.The inflammatory and stress response will influence wound healing from the beginning of trauma through formation of scar.
Factors that can influence wound healing are?
Age of the patient.
Tissue circulation .
The wellbeing of patient.
What will make wound to become complicated?.
Evisceration and dehiscence.
The most common psychological problems about wound are
Body image disturbance.
Fear of the unknown about the wound.
Anxiety about the wound,the smell and people reaction about the wound.
Before you start the dressing change, gather all the supplies that you will need for the dressing change. Don’t let your patient wait for a long time because it can be emotionally draining.
(1)The patient abdominal wound has area with a broken skin.This can be identifies as ?.
(A ) Surgical wound.
(B )Closed wound.
(C) Infected wound.
(D) Open wound.
Correct answer D.
Rationale: Correct answer is D because in an open wound the skin is broken. It may or may not be intentional. If a wound is closed it will not have open area of the skin.There may be tissue damage inside but there is no broken skin.Surgical wound can be closed or open depending on the type of wound.Infected wound has different signs and symptoms to be noted the appearance, smell, odor and exudate.
(2) The doctor orders patient discharge after surgical incision of his right ankle. In teaching the patient with wound about symptoms of infection. The nurse ask patient to call and report?.
(A)Decrease in size of wound.
(B) Temperature of 102.7°F.
(D) Wound granulation.
Correct answer B.
Rationale: Temperature of 102.7 is sign of infection. An elevated temperature is a systemic body response to the presence of infection. A,C, and D all wrong. Decrease in wound size wound granulation are normal signs of a healing wound.Nausea and vomiting is irrelevant to the answers.
3.What indication will show that patient understands the teaching?.
(A )Those heat or cold therapy don’t work.
(B) Why is my leg so swollen.
(C )I feel so floated.
(D )I feel relieved my pain is gone.
Correct answer D.
Rationale: One of the desired outcome is pain relief after cold or heat application. A,B,C are all wrong.
(4 )The doctor removed skin cancer from Mrs Theresa right upper arm. The wound healed very fast with minimal scar.So the wound healed by which process?.
(A) Secondary intention.
(B )Unintentional process.
(C )tertiary intention.
Correct answer D.
Rationale: Surgical incisions heal by primary intention.The wound healed quickly without any delay. Secondary intention also known as secondary healing that occurs when a wound is left open to heal by granulation, contraction and epitheliazation.It goes through four phase Hemostasis(closing by clotting),
Inflammation(Controls bleeding and prevent infection),
Proliferation ( Rebuilding with new tissues made of collagen and extracellular, forming new blood network)and
Remodeling (Known as a maturation phase).It begins about 21days after injury). Tertiary intention in the wound healing is the intentional delay in the closing of the wound because the wound is infected. So the wound are left open covered with a sterile dressing to allow the infection or inflammation to decrease or completely subside. Once the wound is closed with sutures or staples. The wound healing will be quick with minimal scarring.
NB: If wound doesn’t do well during these stages it becomes chronic.