Medical-Surgical Nursing
A 45 years old man admitted with second degree burn injury of 10% in the left arm due to hot water spillage.
During assessment, the nurse would assess the general health of patient and include risk factor for wound healing process. Inflammatory process of wound healing with which of the following?
Explanation
Core Concept: The inflammatory phase is the first stage of wound healing, characterized by hemostasis and the influx of inflammatory cells. Vasodilation leads to the classic signs of inflammation: redness (erythema), heat, swelling, and pain.
Clinical Presentation:
- Erythema, edema, warmth, and pain around the wound or burn site
Diagnosis:
- *First-line:* Clinical visual assessment of the wound.
- *Gold Standard:* Tissue biopsy or culture if infection is suspected (to differentiate normal inflammation from infection).
Management:
- *Acute:* Wound cleaning, debridement if necessary, and appropriate dressings to maintain a moist environment.
- *Definitive:* Nutritional support (protein, vitamin C, zinc) and infection prevention to allow progression to the proliferative phase.