The nurse is teaching a health promotion class for adults about the effects of sun exposure on skin. Which statement about the function of collagen is correct?

A. Increase in monocytes and macrophages. Monocytes and macrophages are key immune cells involved in the inflammatory response. Monocytes migrate to the affected tissue, where they differentiate into macrophages and help clear pathogens, dead cells, and debris. Their presence indicates an ongoing or chronic inflammatory process.
B. Predominance of megakaryocytes. Megakaryocytes are large bone marrow cells responsible for platelet production. They are not involved in inflammation and are typically found in the bone marrow, not in inflamed tissues.
C. Presence of fibroblasts and collagen. Fibroblasts and collagen are associated with tissue repair and scar formation rather than active inflammation. Their presence suggests healing and fibrosis rather than an acute inflammatory response.
D. Prevalence of dead neutrophils. Dead neutrophils are a hallmark of pus formation (suppuration) in bacterial infections but do not necessarily indicate ongoing inflammation. Neutrophils are the first responders in acute inflammation, but their presence alone does not define an inflammatory process—the presence of active immune cells like macrophages is more indicative.

Potential Conditions

Wound healing by secondary intention (Correct): This occurs when the wound is left open to heal from the inside out due to extensive tissue loss, high infection risk, or inability to approximate wound edges. The client’s wound is large, packed with gauze, and not sutured, indicating it is healing by secondary intention.

Wound healing by primary intention (Incorrect): Primary intention healing occurs when wound edges are surgically approximated with sutures or staples, allowing faster healing with minimal scarring. Since the client’s wound is open and packed, this is not the correct choice.

Actions to Take

Use sterile procedure to change dressing (Correct): Using sterile technique reduces the risk of infection and promotes wound healing, which is crucial for open wounds healing by secondary intention.

Encourage the client to consume a balanced diet (Correct): Proper nutrition, especially with protein, vitamin C, and zinc, enhances wound healing by supporting tissue regeneration and immune function.

Culture the wound (Incorrect): A wound culture is only necessary if there are signs of infection, such as increased drainage, foul odor, or worsening erythema. Since there is no mention of infection in the scenario, culturing the wound is not an immediate action.

Parameters to Monitor

Drainage on the dressing (Correct): Monitoring drainage helps assess healing progress and detect infection. An increase in purulent, foul-smelling, or discolored drainage may indicate complications.

The formation of granulation tissue (Correct): Granulation tissue, which is pink and bumpy, indicates healthy wound healing. Lack of granulation tissue suggests delayed healing.

Blood pressure (Incorrect): While blood pressure monitoring is important for overall health, it does not directly indicate wound healing progress.

Intake and output (Incorrect): Although hydration is important for healing, tracking intake and output is more relevant for clients at risk of fluid imbalances rather than wound healing assessment.