Secreting growth factors that stimulate angiogenesis and collagen synthesis is the primary role of macrophages during the proliferative phase. In this phase, macrophages shift from primarily phagocytic activity (in the inflammatory phase) to a reparative role, releasing cytokines and growth factors such as VEGF and TGF-β, which promote new blood vessel formation and stimulate fibroblasts to produce collagen for tissue repair.

Rationale for correct answer:
3. Secreting growth factors: Macrophages act as key regulators of wound healing by promoting angiogenesis, fibroblast proliferation, and extracellular matrix production, all critical for granulation tissue formation.

Rationale for incorrect answers:

1. Initiating vasoconstriction: This is the role of platelets and vascular smooth muscle during the hemostasis phase, not the proliferative phase.

2. Phagocytizing bacteria and debris: This is the main macrophage role in the inflammatory phase, though some clearance may continue early in the proliferative stage.

4. Producing histamine: Histamine release comes mainly from mast cells and basophils during the early inflammatory response, not from macrophages in the proliferative phase.

Take home points:

• The proliferative phase focuses on tissue rebuilding, not just inflammation control.
• Macrophages transition from “clean-up crew” to “construction managers,” directing fibroblasts and endothelial cells.
• Growth factors from macrophages are essential for angiogenesis, collagen deposition, and granulation tissue formation.

Inflammation is the body’s protective response to injury, infection, or irritation. It aims to remove harmful stimuli, initiate tissue repair, and restore homeostasis. Clinically, inflammation is identified by a set of classic physical signs, first described in ancient Roman medicine, which indicate localized vascular and immune system activity in the affected area.

Rationale for correct answers:

1. Tumor: Refers to swelling, which occurs due to fluid accumulation and increased vascular permeability in the inflamed tissue.

3. Calor: Heat develops as a result of increased blood flow (hyperemia) to the inflamed area.

4. Rubor: Redness results from vasodilation and increased perfusion to the site of injury or infection.

5. Dolor: Pain occurs when chemical mediators such as bradykinin and prostaglandins stimulate sensory nerve endings.

Rationale for incorrect answer:
2. Palor: Paleness is not a feature of inflammation; in fact, inflammation typically causes redness (rubor), making palor the opposite of what is expected.

Take home points:

• The classic cardinal signs of inflammation are Rubor (redness), Calor (heat), Tumor (swelling), Dolor (pain), and sometimes Functio laesa (loss of function).
• These signs were first described by the Roman physician Celsus and remain key indicators of inflammation in modern medicine.

The proliferation phase of wound healing is most likely to be delayed or inhibited by the presence of eschar and necrotic tissue. During proliferation, fibroblasts, keratinocytes, and endothelial cells work to form granulation tissue, re-epithelialize the wound, and promote angiogenesis. Necrotic tissue and eschar act as a physical and biological barrier, preventing cell migration, impeding oxygen and nutrient delivery, and increasing infection risk. Debridement is often required to progress healing.

Rationale for correct answer:
3. Proliferation: This phase depends on a clean wound bed for granulation tissue formation and epithelialization. Necrotic tissue and eschar block this process, trapping bacteria and preventing new tissue growth.

Rationale for incorrect answers:
1. Hemostasis: This occurs immediately after injury to stop bleeding and would have already taken place before the proliferation phase begins.
2. Inflammation: While necrotic tissue can prolong inflammation, it doesn’t prevent it; in fact, it often triggers more inflammatory activity.
4. Maturation: This is the final phase involving collagen remodeling and scar strengthening, which occurs after proliferation; it cannot proceed until earlier phases are completed.

Take home points

• The proliferation phase requires a clean, well-vascularized wound bed.
• Necrotic tissue and eschar must be removed to allow granulation and re-epithelialization.
• Without debridement, wounds can stall in the inflammatory phase and fail to progress.

During the inflammatory phase of wound healing, the body responds to injury by initiating immune and vascular processes to prevent infection and prepare the wound for tissue repair. Neutrophils are the first phagocytic cells to arrive, removing debris and bacteria. Local vasodilation increases blood flow, platelets release growth factors and cytokines to recruit immune cells, and increased vascular permeability allows plasma proteins and leukocytes to enter the wound site. Fibroblast migration and collagen synthesis occur later in the proliferative phase, not during inflammation.

Rationale for correct answers:
A. Neutrophils are the first phagocytic cells to arrive: Neutrophils infiltrate the wound within hours, removing pathogens and damaged tissue.
B. Vasodilation of local blood vessels: Mediated by histamine, prostaglandins, and nitric oxide, vasodilation increases delivery of immune cells and nutrients.
C. Platelets release growth factors and cytokines: These signals initiate inflammation and recruit additional immune cells to the wound.
E. Increased vascular permeability: This allows immune cells and plasma proteins to leave the bloodstream and enter the wound area for defense and repair preparation.

Rationale for incorrect answer:
D. Fibroblasts migrate into the wound to begin collagen synthesis: This is a hallmark of the proliferative phase, not the inflammatory phase.

Take home points

• Inflammation involves immune cell recruitment, vasodilation, and increased permeability.
• Platelets not only form clots but also signal immune and repair processes.
• Fibroblast-driven collagen synthesis occurs later, after the wound is cleaned and prepared.

• During the maturation phase of wound healing, fibroblasts play a key role in producing and remodeling the collagen matrix, which increases the wound’s tensile strength. Collagen fibers are reorganized from a random to a parallel alignment, and excess collagen is broken down to improve the functional and structural integrity of the repaired tissue. This phase can last for months to years, depending on the wound.

  Rationale for correct answer:
  C. Producing and remodeling the collagen matrix to increase tensile strength: Fibroblasts are responsible for ongoing collagen production and remodeling, which gradually restores the wound’s structural stability and reduces scar thickness.

  Rationale for incorrect answers:
  A. Clearing the wound of pathogens and dead cells: This is primarily the role of neutrophils and macrophages during the inflammatory phase.
  B. Forming a fibrin clot to stop bleeding: This is the function of platelets during the hemostasis phase.
  D. Creating new blood vessels to supply oxygen and nutrients: This occurs during angiogenesis in the proliferative phase, not during maturation.

  Take home points

• The maturation phase focuses on collagen remodeling and increased tensile strength.
• Fibroblasts remain active long after the wound has closed to optimize scar quality.
• Full tensile strength is never completely restored—healed wounds typically regain about 80% of their original strength.

Modifiable risk factors are those that can be changed or improved to reduce the likelihood of developing pressure ulcers. Immobility can be addressed through repositioning and mobility aids, incontinence can be managed with skin care and protective measures, and nutritional status can be improved with adequate protein, calorie, and micronutrient intake. Age and sensory perception deficits are non-modifiable, though their effects can be mitigated with preventive strategies.

Rationale for correct answers:
A. Immobility: Regular repositioning, mobility exercises, and assistive devices can significantly reduce ulcer risk.
C. Incontinence: Moisture from urine or feces breaks down skin; managing continence and protecting the skin can prevent ulcers.
D. Nutritional status: Adequate nutrition supports skin integrity and wound healing; deficiencies increase ulcer susceptibility.

Rationale for incorrect answers:
B. Age: Older adults are more susceptible due to thinner skin and comorbidities, but age itself cannot be changed.
E. Sensory perception deficits: Conditions like neuropathy reduce the ability to feel pressure, but the underlying deficit cannot be reversed (though compensatory measures can help).

Take home points

• Modifiable factors can be improved to lower ulcer risk, even in high-risk patients.
• Immobility, moisture, and poor nutrition are major preventable contributors.
• Non-modifiable risks require compensatory preventive care rather than direct change.

The primary cause of a pressure ulcer is prolonged compression of soft tissue between a bony prominence and an external surface. This sustained pressure exceeds capillary closing pressure, leading to impaired blood flow, tissue ischemia, and eventual cell death. While shear, friction, and moisture can worsen skin breakdown, they are considered contributing factors rather than the main cause.

Rationale for correct answer:
C. Compression of soft tissue between a bony prominence and an external surface: Continuous pressure obstructs blood supply, depriving tissues of oxygen and nutrients, which leads to ischemia and necrosis.

Rationale for incorrect answers:
A. Shear force, which is the stretching of the blood vessels: Shear exacerbates injury by distorting tissues and damaging blood vessels, but it is secondary to direct pressure.
B. Friction, which is the rubbing of skin against a surface: Friction removes superficial skin layers, increasing vulnerability but does not directly cause deep tissue ischemia.
D. Moisture, which leads to skin maceration: Moisture weakens the skin and increases susceptibility to pressure injury but is not the initiating cause.

Take home points

• Prolonged pressure over bony prominences is the main driver of pressure ulcer formation.
• Shear, friction, and moisture accelerate damage when pressure is already present.
• Prevention strategies focus on pressure redistribution and regular repositioning.

A shallow, open ulcer with a red-pink wound bed and no slough is characteristic of a Stage 2 pressure ulcer. This stage involves partial-thickness loss of the dermis and may present as an open ulcer or an intact/ruptured serum-filled blister. There is no exposure of subcutaneous tissue, muscle, or bone at this stage.

Rationale for correct answer:
B. Stage 2 pressure ulcer: Defined by partial-thickness skin loss involving the epidermis and/or dermis, presenting with a red-pink wound bed without slough.

Rationale for incorrect answers:
A. Stage 1 pressure ulcer: Involves non-blanchable erythema of intact skin, without ulceration or open wound.
C. Stage 3 pressure ulcer: Involves full-thickness skin loss with possible exposure of subcutaneous fat but no bone, tendon, or muscle.
D. Unstageable pressure ulcer: The wound base is obscured by slough or eschar, preventing accurate staging until debridement.

Take home points

• Stage 2 ulcers are partial-thickness and present as shallow red-pink wounds or blisters.
• Absence of slough and exposure of deeper structures differentiates Stage 2 from more severe stages.
• Accurate staging guides treatment and monitoring of healing progress.

A pressure ulcer covered completely by thick, black eschar is classified as unstageable because the wound bed and depth cannot be visualized. Debridement is typically necessary to remove the eschar and reveal the underlying tissue damage for accurate staging. Once treated, such wounds usually heal by secondary intention, where granulation tissue gradually fills the defect from the base upward.

Rationale for correct answers:
A. The true stage of the ulcer cannot be determined: The eschar blocks visibility of the wound base, making staging impossible until removal.
C. Debridement is necessary to determine the stage: Without removing the necrotic tissue, the extent of damage cannot be assessed.
D. The wound is likely to heal by secondary intention: This type of wound closes gradually through granulation tissue formation, contraction, and epithelialization.

Rationale for incorrect answer:
B. The wound bed is likely to be a Stage 2 or 3 ulcer beneath the eschar: The actual depth could range from Stage 3 to Stage 4; it cannot be assumed without direct visualization.

Take home points

• Ulcers fully covered by eschar are unstageable until debridement reveals the true depth.
• Secondary intention healing is common for deep pressure ulcers.
• Accurate staging is essential for selecting appropriate treatment and predicting outcomes.

B. Higher risk for pressure ulcer development: Scores of 18 or lower typically signal increased risk, with lower numbers indicating more severe risk factors.

Rationale for incorrect answers:
A. Lower risk for pressure ulcer development: A higher, not lower, Braden score indicates reduced risk.
C. The patient's skin is intact: Skin status is assessed separately; intact skin does not guarantee a low risk for ulcers.
D. The patient is fully mobile: Mobility is one factor in the scale, but the total score considers multiple risk factors.

When teaching a family member about preventing pressure ulcers, the nurse should emphasize repositioning the patient at least every two hours, keeping the skin clean and dry to prevent maceration, encouraging a high-calorie, high-protein diet to promote skin integrity and healing, and providing range-of-motion exercises to improve circulation and reduce immobility. Donut-shaped cushions should be avoided because they concentrate pressure on surrounding tissue and can worsen skin breakdown.

Rationale for correct answers:
A. Repositioning the patient at least every two hours: Reduces prolonged pressure on bony prominences and promotes blood flow.
B. Keeping the skin clean and dry: Moisture control prevents maceration and reduces infection risk.
C. Encouraging the patient to eat a high-calorie, high-protein diet: Adequate nutrition supports skin repair and immune defense.
E. Providing range-of-motion exercises: Helps maintain mobility, prevent stiffness, and improve circulation.

Rationale for incorrect answer:
D. Using a donut-shaped cushion when the patient is sitting: These can create localized areas of high pressure, increasing the risk of ulcer development.

Take home points

• Prevention strategies focus on pressure relief, moisture control, good nutrition, and mobility.
• Donut-shaped cushions are harmful and should be avoided.
• Family education is essential to ensure consistent preventive care at home.

The most appropriate action to prevent a pressure ulcer from becoming infected is ensuring proper hand hygiene and using aseptic technique during dressing changes. This reduces the introduction of pathogens into the wound and helps maintain a clean healing environment. While dressings, debridement, and antibiotics may be part of treatment, infection prevention starts with meticulous aseptic care.

Rationale for correct answer:
C. Ensuring proper hand hygiene and using aseptic technique during dressing changes: This is the most effective first-line measure to prevent contamination and infection in an open wound.

Rationale for incorrect answers:
A. Applying a transparent film dressing to the ulcer: May protect against external contaminants, but does not replace the need for aseptic handling.
B. Debriding the wound with a scalpel: Debridement is performed to remove necrotic tissue, but it is not specifically the primary infection prevention measure.
D. Administering a broad-spectrum antibiotic intravenously: Antibiotics are used when infection is present; they are not given prophylactically for all ulcers due to resistance risk.

Take home points

• Hand hygiene and aseptic technique are the foundation of infection prevention in wound care.
• Dressings and debridement support healing but are secondary to proper sterile handling.
• Antibiotics should be reserved for confirmed or strongly suspected infections, not routine prevention.

For a patient with a Stage 4 pressure ulcer, adequate nutrition is essential to promote tissue repair and immune function. Increasing protein intake supports collagen synthesis and granulation tissue formation, vitamin C and zinc aid in collagen production and immune defense, and fruits and vegetables provide antioxidants, vitamins, and minerals that support healing. Fluid restriction and caloric restriction are generally not recommended unless medically indicated, as adequate hydration and energy intake are vital for repair.

Rationale for correct answers:
B. Increasing protein intake: Protein is essential for rebuilding damaged tissue and supporting immune function.
C. Providing vitamin C and zinc supplements: Vitamin C promotes collagen synthesis; zinc supports cell proliferation and immune function.
E. Increasing the intake of fruits and vegetables: Supplies essential vitamins, minerals, and antioxidants for wound healing and overall health.

Rationale for incorrect answers:
A. Limiting fluid intake to prevent edema: Adequate hydration is necessary for wound healing; fluid restriction can impair tissue repair unless clinically required.
D. Restricting caloric intake to prevent weight gain: Healing requires increased energy; calorie restriction can delay repair and worsen outcomes.

Take home points

• Wound healing demands increased protein, micronutrients, and antioxidants.
• Hydration and sufficient caloric intake are essential for repair.
• Nutritional deficiencies can significantly delay healing in advanced pressure ulcers.

A pressure ulcer with full-thickness tissue loss and visible subcutaneous fat, but without exposed bone, tendon, or muscle, is classified as Stage C. This stage may include undermining or tunneling, and slough may be present, but it does not obscure the depth of tissue loss.

Rationale for correct answer:
C. Stage 3: Defined by full-thickness skin loss extending into the subcutaneous tissue, with fat visible but no exposure of deeper structures such as bone or muscle.

Rationale for incorrect answers:
A. Stage 1: Involves non-blanchable erythema of intact skin, without any break in the surface.
B. Stage 2: Involves partial-thickness skin loss, presenting as a shallow ulcer or blister without visible fat or deeper structures.
D. Stage 4: Involves full-thickness tissue loss with exposed bone, tendon, or muscle, often with undermining or tunneling.

Take home points

• Stage 3 ulcers show full-thickness skin loss with visible subcutaneous fat but no deeper tissue exposure.
• Staging guides treatment and helps track healing progress.
• Correct identification ensures appropriate interventions to prevent further deterioration.

The most effective way to reduce pressure on a wound is by using specialized support surfaces, such as pressure-relieving mattresses or cushions. These devices help distribute weight more evenly, reduce pressure over bony prominences, and promote circulation, which is critical for healing. While dressings, elevation, and wound VACs can aid in healing, they do not directly relieve pressure to the same extent.

Rationale for correct answer:
C. Using specialized support surfaces, such as a pressure-relieving mattress or cushion: These are specifically designed to minimize sustained pressure, preventing further tissue damage and supporting wound healing.

Rationale for incorrect answers:
A. Using a wound vacuum-assisted closure (VAC) device: Promotes healing by removing exudate and improving blood flow, but it does not address the root cause of pressure injury—sustained pressure.
B. Elevating the affected body part with pillows: Can help in certain cases but may create new pressure points and is less effective than a full support surface.
D. Applying a hydrocolloid dressing to the wound: Helps maintain a moist healing environment but does not reduce pressure.

Take home points

• Pressure redistribution is the most important intervention for healing pressure ulcers.
• Support surfaces complement, but do not replace, repositioning schedules.
• Treating the cause (pressure) is as important as treating the wound itself.

The normal inflammatory response is a complex and essential defense mechanism triggered by tissue injury, infection, or harmful stimuli. It involves vascular changes, cellular infiltration, and the release of chemical mediators like histamine, prostaglandins, and cytokines. This response aims to eliminate the cause of injury, clear out damaged cells, and initiate tissue repair. Recognizing the signs of acute inflammation, including redness, swelling, heat, pain, and loss of function, is critical in clinical assessment.

Rationale for Correct Answer:
B. The described findings are consistent with a normal localized inflammatory response to surgery. Mild fever (under 100.4°F), incisional discomfort, slight redness, and minimal serosanguineous drainage are common in the immediate postoperative period and typically resolve as healing progresses.

Rationale for Incorrect Answers:
A. Signs of infection include increasing erythema, purulent drainage, swelling, worsening pain, and a temperature greater than 100.4°F. The patient's symptoms do not meet the criteria for infection.
C. Impending dehiscence is often signaled by sudden drainage of large amounts of serosanguineous fluid, separation of wound edges, or visible underlying tissue. These signs are not present in this case.
D. Notifying the physician is not necessary at this time since the findings are within expected postoperative parameters. Routine monitoring is appropriate unless changes occur.

Key Takeaways:

• Mild erythema, low-grade fever, and minimal drainage are expected in early postoperative healing.
• A normal inflammatory response should not be mistaken for infection or dehiscence.
• Knowing typical vs. abnormal postoperative signs is essential for accurate nursing assessments.

The systemic response to inflammation occurs when inflammatory mediators affect the entire body rather than just the site of injury. Key features include fever, leukocytosis, malaise, anorexia, and increased heart rate and respiratory rate. These effects are triggered by cytokines such as interleukin-1 (IL-1) and tumor necrosis factor (TNF) released into the bloodstream. The systemic response plays a vital role in enhancing immune function and supporting the body’s effort to fight infection or injury.

Rationale for Correct Answer:
B. WBC count and differential are standard laboratory tests used to evaluate for systemic inflammation or infection. In a patient with local signs such as erythema and pain, the WBC can help determine whether the infection is spreading or remains localized.

Rationale for Incorrect Answers:
A. Serum protein analysis evaluates nutritional status and protein levels (e.g., albumin), which can affect wound healing, but it does not directly assess for systemic infection or inflammation.
C. A punch biopsy can provide histological information about chronic wounds, especially if malignancy or atypical causes are suspected, but it is not routinely used to assess systemic response.
D. Culture and sensitivity are used to identify the causative organism at the wound site and guide antibiotic therapy but do not measure the body’s systemic response to infection.

Key Takeaways:

• A WBC count with differential helps determine the presence and extent of systemic infection or inflammation.
• Culture and sensitivity assess local infection but not systemic response.
• Nutritional markers and biopsy may support wound management but are not first-line tests for systemic assessment.

Fever management involves strategies to reduce elevated body temperature and alleviate discomfort while addressing the underlying cause. Key interventions include administering antipyretic medications such as acetaminophen or ibuprofen, promoting adequate fluid intake to prevent dehydration, and ensuring rest to conserve energy. In cases of high fever, cooling measures like tepid sponge baths or a cooling blanket may be used. It is important to monitor for signs of infection, dehydration, and worsening symptoms requiring further medical attention.

Rationale for Correct Answer:
B. Antipyretics such as acetaminophen or ibuprofen act on the hypothalamus to lower the body’s set point for temperature regulation. Administering them on a scheduled basis helps control fever more effectively than PRN dosing, preventing temperature spikes and promoting patient comfort.

Rationale for Incorrect Answers:
A. A cooling blanket may be used for very high fevers, but it can cause shivering, which increases metabolic demand and discomfort. It is typically reserved for heatstroke or when antipyretics are ineffective.
C. Increased fluids and sponge baths help with hydration and comfort but do not directly affect the hypothalamic temperature regulation set point. These are supportive measures, not primary interventions.
D. Antibiotics treat the underlying cause if the fever is due to a bacterial infection, but they do not directly reduce fever. Warm blankets may provide comfort during chills but will not help reduce body temperature.

Key Takeaways:

• Around-the-clock antipyretic administration is the most effective intervention for sustained fever reduction.
• Supportive measures like fluids and sponge baths help with comfort but do not replace pharmacologic treatment.
• Cooling blankets and antibiotics have specific roles but are not first-line interventions for fever control.

Healing by secondary intention occurs when a wound is left open and allowed to heal naturally without primary closure. This process is typical for wounds with extensive tissue loss, infection, or irregular wound edges, such as pressure ulcers, traumatic injuries, or surgical wounds left open. Healing involves granulation tissue formation, wound contraction, and epithelialization, resulting in longer healing time, increased scar formation, and higher risk of infection compared to primary intention healing.

Rationale for Correct Answer:
B. Secondary intention healing is typical for pressure ulcers and other wounds with significant tissue loss. These wounds are not closed surgically but instead heal gradually through the formation of granulation tissue, wound contraction, and epithelialization over time.

Rationale for Incorrect Answers:
A. Tertiary intention healing (also called delayed primary closure) involves initially leaving a wound open due to contamination or infection risk, then surgically closing it later. This is not typical for pressure ulcers managed conservatively.
C. Regeneration of cells refers to the replacement of lost cells with the same type of cells (as in superficial skin wounds or liver tissue), but pressure ulcers usually involve deeper tissue layers requiring granulation and scarring.
D. Remodeling of tissues is the final phase of wound healing, not the type or process of healing. It involves strengthening of collagen and scar formation after the wound has closed.

Key Takeaways:

• Pressure ulcers typically heal by secondary intention due to tissue loss and open wound management.
• Secondary intention involves granulation, contraction, and epithelialization.
• Tertiary intention and regeneration apply to different wound contexts and healing types.

Several factors affect wound healing, influencing the speed and quality of recovery. Local factors include infection, poor blood supply, edema, and excessive pressure at the wound site. Systemic factors involve age, nutritional status, chronic diseases such as diabetes, smoking, obesity, and the use of immunosuppressive drugs like corticosteroids. Effective wound care requires addressing both local and systemic factors to promote tissue regeneration, prevent complications, and support optimal healing outcomes.

Rationale for Correct Answer:
C. Diabetes and smoking both lead to vascular damage and peripheral arterial disease, severely impairing tissue perfusion. Impaired blood flow prevents oxygen and nutrient delivery to the wound, which is essential for healing. This makes ineffective peripheral tissue perfusion the most critical concern.

Rationale for Incorrect Answers:
A. While imbalanced nutrition contributes to poor healing, in this case it is not the most immediate or primary barrier. The necrosis and need for amputation point to severely compromised circulation as the priority.
B. Impaired tissue integrity reflects the wound’s condition, but it does not directly address the underlying cause of poor healing. A diagnosis focusing on perfusion is more appropriate and foundational.
D. Coping may be an issue, but addressing physiological needs like perfusion takes priority in wound healing and surgical recovery.

Key Takeaways:

• Peripheral perfusion is essential for tissue healing, especially in diabetic clients with vascular disease.
• Smoking and diabetes compound the risk of poor wound healing due to impaired circulation.
• Addressing ineffective perfusion takes precedence over nutritional or psychosocial concerns in this context.

Care for a stage III pressure ulcer focuses on promoting healing, preventing infection, and relieving pressure. These full-thickness wounds extend into subcutaneous tissue but not through underlying fascia. Key interventions include regular repositioning to reduce pressure, using pressure-relieving devices (e.g., specialty mattresses), cleansing the wound with non-cytotoxic solutions, and debriding necrotic tissue as needed. Apply moist dressings like foam or hydrocolloid, monitor for signs of infection, and ensure adequate nutrition to support tissue repair.

Rationale for Correct Answer:
C. Dakin’s solution is cytotoxic and can harm viable tissue if used too frequently or without clear indication of heavy infection. Its routine use every shift is not evidence-based for a stage III pressure ulcer, which requires promotion of healing through preservation of healthy tissue and moisture balance.

Rationale for Incorrect Answers:
A. Packing with foam dressing is appropriate for stage III ulcers, which may have depth requiring absorbent and conformable dressings that maintain moisture and fill dead space.
B. Turning and positioning every 2 hours is a critical intervention to prevent worsening of pressure ulcers and support healing by reducing pressure on affected areas.
D. Pain assessment and pre-medication before dressing changes are standard practice to improve patient comfort and compliance with wound care.

Key Takeaways:

• Dakin’s solution can impair healing if used excessively due to its cytotoxic effects.
• Appropriate wound care for stage III ulcers includes moist dressings, pressure relief, and pain control.
• Nursing interventions should support healing while minimizing tissue damage.

Pressure ulcer prevention involves strategies to reduce prolonged pressure, enhance skin integrity, and promote mobility. Key interventions include frequent repositioning (at least every 2 hours), using pressure-relieving surfaces such as specialty mattresses or cushions, and conducting daily skin assessments for early signs of breakdown. Maintain clean, dry skin, manage moisture from incontinence or perspiration, ensure adequate hydration and nutrition, and encourage mobility or activity as tolerated to reduce the risk of pressure injury.

Rationale for Correct Answer:
A. A Braden Scale score of 16 signifies moderate risk for skin breakdown. Evidence-based care for such patients includes repositioning every 2 hours and routine skin assessments to prevent pressure ulcer development.

Rationale for Incorrect Answers:
B. DuoDerm is typically used to protect areas at higher risk or to treat existing ulcers. It may be appropriate later but is not the first-line preventive action for a score of 16.
C. Elevating the head of bed to 90 degrees increases pressure and shear on the sacrum and is contraindicated in patients at risk for skin breakdown.
D. Weekly skin assessments without any special precautions are inadequate for someone with a moderate risk. Regular assessment and repositioning are essential.

Key Takeaways:

• A Braden Scale score of 16 indicates moderate risk and necessitates proactive measures.
• Turning every 2 hours and frequent skin assessments are standard prevention practices.
• Avoid high Fowler's position (90°) to reduce shear and pressure on vulnerable areas.

A pressure ulcer, also known as a decubitus ulcer or bedsore, is a localized injury to the skin and underlying tissue usually over a bony prominence, caused by prolonged pressure, shear, or friction. These ulcers commonly develop in individuals with limited mobility, such as those who are bedbound or wheelchair-bound. Pressure ulcers are staged from Stage I (non-blanchable erythema) to Stage IV (full-thickness tissue loss with exposed bone, tendon, or muscle). Prevention and early intervention are key to improving outcomes.

Rationale for Correct Answers:
A. Acute pain is appropriate because deep tissue injuries can be painful due to underlying tissue inflammation and damage.

B. The patient is experiencing reduced mobility and sensation, increasing their risk for skin breakdown
C. Impaired tissue integrity is the correct diagnosis for suspected deep tissue injury, which affects underlying tissues and not just the skin surface.
D. Risk for infection is valid as tissue breakdown compromises the skin barrier, and undernutrition post-stroke further impairs immune response and healing capacity.

Key Takeaways:

• Deep tissue injuries are best described by impaired tissue integrity, not skin integrity.
• Pain and risk for infection are key concerns in managing pressure-related injuries.
• Accurate nursing diagnoses guide appropriate interventions and care planning.

Pressure ulcer staging is a standardized method used by healthcare professionals to assess the severity, depth, and extent of tissue damage caused by prolonged pressure. Accurate staging is essential for effective treatment planning, monitoring wound healing, and preventing complications. The stages range from non-blanchable erythema in intact skin to full-thickness tissue loss with exposed muscle or bone, including unstageable wounds and suspected deep tissue injuries.

Rationale for Correct Answer:
C. Stage III pressure ulcers involve full-thickness tissue loss with visible subcutaneous fat. The presence of depth (0.8 cm) and exposure of subcutaneous tissue confirms it is beyond a superficial wound, placing it in Stage III.

Rationale for Incorrect Answers:
A. Stage I involves intact skin with non-blanchable erythema—there is no open wound or tissue loss.
B. Stage II includes partial-thickness loss of dermis and presents as a shallow open ulcer, but subcutaneous tissue is not exposed.
D. Stage IV includes full-thickness tissue loss with exposed bone, tendon, or muscle—none of which are visible in this case.

Key Takeaways:

• Stage III ulcers show full-thickness tissue loss with subcutaneous fat visible but no exposure of bone or muscle.
• Stage II ulcers involve partial-thickness skin loss, while Stage IV involves deeper structures like bone or tendon.
• Accurate staging is essential for appropriate wound care planning and documentation.

The RICE method—Rest, Ice, Compression, and Elevation—is a first-line intervention used to manage soft tissue injuries such as sprains, strains, and contusions. This approach helps reduce inflammation, minimize pain, and promote healing. Rest prevents further injury, ice constricts blood vessels to decrease swelling, compression supports the injured area, and elevation aids in venous return, reducing fluid accumulation and tissue damage.

Rationale for Correct Answer:
C. RICE stands for Rest, Ice, Compression, and Elevation. These actions reduce swelling, limit further injury, decrease pain, and promote healing in acute soft tissue injuries such as ankle sprains.

Rationale for Incorrect Answers:
A. Shining light on the wound and eliciting history are not part of RICE and do not address immediate injury management.
B. Rubbing the wound clean is inappropriate and can cause further tissue damage. Exercising the leg immediately after injury can worsen it.
D. Rinsing the wound and imaging may be needed but are not components of the RICE protocol. Carrying and extending the ankle are also not appropriate immediate interventions.

Key Takeaways:

• RICE stands for Rest, Ice, Compression, and Elevation, and is the standard first-aid for soft tissue injuries.
• These measures help reduce inflammation, swelling, and pain.
• Immediate exercise or rubbing the wound can worsen injury and delay healing.

Chronic inflammation is a prolonged and often maladaptive immune response that can last for weeks, months, or even years. Unlike acute inflammation, which resolves after the harmful stimulus is removed, chronic inflammation occurs when the injurious agent persists or the body’s immune regulation fails. It is characterized by ongoing tissue destruction, lymphocyte and macrophage infiltration, and fibrosis or scarring. Chronic inflammation underlies many conditions like rheumatoid arthritis, inflammatory bowel disease, and atherosclerosis.

Rationale for Correct Answer:
B. Chronic inflammation occurs when the harmful stimulus is not removed, causing ongoing tissue injury and repair. This leads to a prolonged inflammatory response that can last months or years.

Rationale for Incorrect Answers:
A. Inflammation lasting 2 to 3 weeks is more typical of subacute or acute inflammation, not chronic.
C. Infective endocarditis may have both acute and chronic features but is not exclusively a classic example of chronic inflammation.
D. Neutrophils dominate in acute inflammation; chronic inflammation is characterized more by macrophages, lymphocytes, and plasma cells.

Key Takeaways:

• Chronic inflammation involves a persistent or recurring injurious agent.
• It leads to prolonged tissue damage and repair, often involving different immune cells than acute inflammation.
• Neutrophils are predominant in acute inflammation, whereas chronic inflammation involves macrophages and lymphocytes.

Healing by primary intention refers to the process in which a clean surgical or traumatic wound with well-approximated edges heals with minimal tissue loss and low risk of infection. This type of healing involves epithelial regeneration, minimal granulation tissue formation, and rapid wound closure. Typically seen in surgical incisions closed with sutures, staples, or adhesive strips, primary intention results in faster healing, less scarring, and a lower complication rate compared to other healing types.

Rationale for Correct Answer:
C. Secondary intention healing occurs when wounds are left open to heal naturally, resulting in abundant granulation tissue formation and a larger scar. Primary intention involves clean, surgically closed wounds with minimal granulation and scarring.

Rationale for Incorrect Answers:
A. Secondary healing does not always require surgical debridement; it depends on wound condition.
B. Primary healing involves suturing the edges of a clean wound, not suturing granulation tissue.
D. Secondary intention takes longer, but the main difference is the amount of granulation tissue and scarring, not merely the number of healing steps.

Key Takeaways:

• Primary intention involves direct closure with minimal granulation and scarring.
• Secondary intention involves open wound healing with extensive granulation and more scarring.
• Healing duration is longer in secondary intention due to tissue loss and repair needs.

Yellow wounds are characterized by the presence of slough, which is a soft, moist, yellowish necrotic tissue made up of dead white blood cells, fibrin, and cellular debris. These wounds often have drainage and may show signs of infection or delayed healing. The primary goal in managing yellow wounds is to remove slough through cleansing, irrigation, or debridement, and to create a moist wound environment that promotes granulation tissue formation and tissue regeneration.

Rationale for Correct Answer:
D. Yellow wounds contain slough, which appears as creamy or yellow-green drainage. This exudate often indicates the presence of dead tissue and possibly infection, requiring cleansing and debridement.

Rationale for Incorrect Answers:
A. Serosanguineous drainage is usually seen in clean, healing wounds and is more associated with red wounds.
B. Adherent gray necrotic tissue describes a black wound with eschar, not a yellow wound.
C. Clean, moist granulating tissue is characteristic of a red wound, indicating healthy healing tissue.

Key Takeaways:

• Yellow wounds contain slough and have yellowish exudate, requiring cleansing.
• Red wounds show granulation tissue and are signs of healing.
• Black wounds have necrotic eschar and require debridement.

Risk factors for pressure ulcers include conditions and circumstances that compromise skin integrity or reduce blood flow, leading to tissue breakdown. Key risk factors are immobility, incontinence, malnutrition, advanced age, neurological impairments, and chronic illnesses such as diabetes or vascular disease. Other contributors include friction, shear, and moisture, which weaken the skin barrier. Identifying these risk factors early allows for targeted preventive interventions to reduce the risk of pressure ulcer development.

Rationale for Correct Answer:
C. Comatose patients have severely limited mobility and impaired ability to sense and respond to pressure, which greatly increases the risk of pressure ulcer development. Prolonged immobility and inability to reposition independently are primary risk factors.

Rationale for Incorrect Answers:
A. Although obesity and diabetes increase risk factors for complications, the patient’s mobility is likely better preserved compared to a comatose patient.
B. Advanced age, confusion, and malnutrition increase risk but a comatose state generally presents a more immediate and severe risk due to total immobility.
D. Incontinence increases moisture-related skin breakdown but is less critical compared to the immobility and sensory loss in coma.

Key Takeaways:

• Complete immobility and inability to reposition, such as in coma, is a major risk factor for pressure ulcers.
• Sensory loss and impaired consciousness increase risk due to lack of protective responses.
• Other factors like malnutrition, age, and incontinence compound the risk but immobility is the greatest risk.

A wound VAC (Vacuum-Assisted Closure) is a type of negative pressure wound therapy used to promote wound healing in both acute and chronic wounds. The device uses controlled suction to remove exudate, decrease bacterial load, and increase blood flow to the wound bed. A foam dressing is applied to the wound, sealed with an occlusive drape, and connected to a vacuum pump. This method supports the formation of granulation tissue and faster wound closure.

Rationale for Correct Answer:
C. The wound vac works by applying negative pressure to the wound through a sealed, airtight dressing. Proper sealing is essential to maintain suction, remove exudate, reduce edema, and promote granulation tissue formation.

Rationale for Incorrect Answers:
A. The wound is not cleaned daily; the dressing changes and wound care follow specific protocols, often less frequently than daily.
B. Hyperbaric oxygen therapy is a separate treatment and not part of wound vac therapy.
D. Nutrition remains critically important for wound healing, even when using wound vac therapy.

Key Takeaways:

• A tightly sealed occlusive dressing is essential for effective negative pressure wound therapy.
• Wound vac therapy promotes healing by removing fluid and stimulating tissue growth.
• Proper nutrition continues to play a vital role in wound healing with or without wound vac therapy.