A patient has a healing abdominal wound. The wound has minimal exudate and collagen formation. How should the nurse document this wound in the patient's chart?
a. Primary intention
b. Inflammatory phase
c. Proliferative phase
d. Secondary intention
C
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A Primary intention is not a phase of wound healing. Wounds that heal by primary intention have minimal tissue loss, such as a surgical wound. The edges are approximated, and the risk of infection is low.
B During the inflammatory phase, platelets gather to stop bleeding, a fibrin matrix forms, and white blood cells reach the wound, clearing it of debris.
C During the proliferative phase, the wound fills with granulation tissue (including collagen formation), the wound contracts, and the wound is resurfaced by epithelialization.
D Secondary intention is not a phase of wound healing. Wounds that heal by secondary intention have loss of tissue, such as a pressure ulcer. The wound is left open until it becomes filled by scar tissue.
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