A nurse is caring for a client who has a surgical incision with sutures. The nurse observes that the edges of the wound are well approximated and there is minimal drainage from the site. The nurse documents this type of wound healing as:

Answer: A

Primary intention is a type of wound healing that occurs when the edges of the wound are well approximated and there is minimal tissue loss or infection. It results in minimal scarring and fast healing.

B. Secondary intention is a type of wound healing that occurs when the edges of the wound are not approximated or there is extensive tissue loss or infection. It results in granulation tissue formation, contraction, and epithelialization. It takes longer to heal and may result in scarring and infection.

C. Tertiary intention is a type of wound healing that occurs when there is a delay in closing the wound or when the wound is intentionally left open for drainage or debridement. It results in less scarring than secondary intention but more than primary intention.

D. Quaternary intention is not a valid term for wound healing.

Answer: A

To reduce edema and venous pressure is the rationale for elevating the leg above the level of the heart whenever possible. Venous ulcers are caused by chronic venous insufficiency, which impairs venous return and causes blood pooling, increased venous pressure, and edema in the lower extremities. Elevation helps to facilitate venous return and reduce edema and venous pressure, which improves wound healing.

B. To increase arterial blood flow and oxygenation is not the rationale for elevating the leg above the level of the heart whenever possible. Arterial ulcers are caused by arterial insufficiency, which impairs arterial blood flow and oxygenation to the lower extremities. Elevation may worsen arterial blood flow and oxygenation, as it reduces the effect of gravity on arterial perfusion.

C. To prevent infection and inflammation is not the rationale for elevating the leg above the level of the heart whenever possible. Infection and inflammation are complications of venous ulcers, but they are not directly affected by elevation. Infection and inflammation are prevented by proper wound care, such as cleansing, dressing, debridement, and antibiotic therapy.

D. To stimulate nerve regeneration and sensation doesn’t help with venous ulcers.