e.Age: Older people are good candidates for pres-
sure ulcers because their skin is susceptible to
injury.
f. Immobility: Causes prolonged pressure on body
areas
4.Sample answer:
Provide the caregivers with a simple, easy-to-under-
stand list of instructions about caring for the
pressure ulcer; address the causative factor for the
pressure ulcer before proceeding with the plan of
care; consult frequently with the physician about
the progress of wound healing and products being
used; use clean dressings; teach caregivers good
handwashing technique; review signs of infection
with caregivers and encourage them to contact a
physician or home health nurse about any problems.- a.Hemostasis: Hemostasis occurs immediately
after the initial injury. Involved blood vessels
constrict and blood clotting begins through
platelet activation and clustering. After only a
brief period of constriction, these same blood
vessels dilate and capillary permeability
increases, allowing plasma and blood
components to leak out into the area that is
injured, forming a liquid called exudate.
b.Inflammatory phase: The inflammatory phase
follows hemostasis and lasts about 4 to 6 days.
White blood cells, predominantly leukocytes
and macrophages, move to the wound. About
24 hours after the injury, macrophages enter
the wound area and remain for an extended
period. Macrophages are essential to the heal-
ing process. They not only ingest debris, but
also release growth factors that are necessary
for the growth of epithelial cells and new
blood vessels. These growth factors also attract
fibroblasts that help to fill in the wound,
which is necessary for the next stage of heal-
ing. Acute inflammation is characterized by
pain, heat, redness, and swelling at the site of
the injury.
c. Proliferative phase: Begins about day 2 or 3 up
to 2 to 3 weeks. New tissue is built to fill the
wound space (action of fibroblasts). Capillaries
grow across the wound, fibroblasts form fibrin
that stretches through the clot, a thin layer of
epithelial cells forms across the wound, and
blood flow is reinstituted. Granulation tissue
forms the foundation for scar tissue.
d.Maturation phase: Begins about 3 weeks after
injury, up to 6 months if wound is large. Colla-
gen is remodeled, new collagen is deposited,
and avascular collagen tissue becomes a flat,
thin white line.
6.Sample answers:
a.The patient will participate in the prescribed
treatment regimen to promote wound healing.
b.The patient will remain free of infection at the
site of the pressure ulcer.
c. The patient will demonstrate self-care measures
necessary to prevent the development of a pres-
sure ulcer.
7.Sample answers:
a.Overall appearance of skin: Are there any areas
on your body where your skin feels paper thin?
How does your skin feel in relation to
moisture—dry, clammy, oily?
b.Recent changes in skin condition: Have you
noticed any sores anywhere on your body? Do
you ever notice any redness over a bony area
when you stay in one position for a while?
c. Activity/mobility: Do you need assistance to
walk to the bathroom? Can you change your
position freely and painlessly?
d.Nutrition: Have you lost weight lately? Do you
eat well-balanced meals?
e.Pain: Do you have any painful sores on your
body? Do you take any medications for pain?
f. Elimination: Do you have any problems with
incontinence? Have you ever used any briefs or
pads for incontinence problems?- a.Appearance: Assess for the approximation of
wound edges, color of the wound and surround-
ing areas, drains or tubes, sutures, and signs of
dehiscence or evisceration.
b.Wound drainage: Assess the amount, color,
odor, and consistency of wound drainage.
Drainage can be assessed on the wound, the
dressings, in drainage bottles or reservoirs, or
under the patient.
c. Pain: Assess whether the pain has increased or
is constant; pain may indicate delayed healing
or an infection.
d.Sutures and staples: Assess the type of suture
and whether enough tensile strength has devel-
oped to hold the wound edges together during
healing.
9.Provide physical, psychological, and aesthetic
comfort; remove necrotic tissue; prevent, eliminate,
or control infection; absorb drainage; maintain a
moist wound environment; protect the wound
from further injury; and protect the skin surround-
ing the wound. - a.R red protect: Red wounds are in the prolif-
erative stage of healing and are the color of nor-
mal granulation. They need protection by
gentle cleansing, using moist dressings, apply-
ing a transparent or hydrocolloid dressing, and
changing the dressing only when necessary.
b.Y yellow cleanse: Yellow wounds are char-
acterized by oozing from the tissue covering
the wound, often accompanied by purulent
drainage. They need to be cleansed using
irrigation; wet-to-moist dressings; using nonad-
herent, hydrogel, or other absorptive dressings;
and topical antimicrobial medication.
c. B black débride: Black wounds are covered
with thick eschar, which is usually black but
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