A nurse is caring for a patient who has developed a stage I pressure ulcer in the area of the right ischial tuberosity. Which of the following should the nurse plan to apply to the ulcer?
-Barrier creams and ointments are used for patients prone to skin breakdown from pressure, shear, or incontinence. They are intended for prevention and for resolving new- onset problems, such as a stage I pressure ulcer.
A nurse is caring for a patient who has a heavily draining wound that continues to show evidence of bleeding. Which of the following types of dressings should the nurse select to help promote hemostasis?
-Alginate dressing help establish hemostasis while providing a moist environment for healing and good absorption of exudate. They do not adhere to the wound; therefore, removal is unlikely to cause further bleeding.
A nurse is caring for a patient who has multiple sclerosis and has a chronic nonhealing wound. The nurse should recognize that which of the following types of medications is known to delay wound healing?
-Corticosteroids suppress the immune system and therefore can delay wound healing
A nurse is caring for a patient with a stage IV sacral pressure ulcer for which the provider has prescribed mechanical debridement. Which of the following should the nurse plan for this patient?
Changing dressings using the wet-to-dry method.
-A wet-to-dry saline dressing provides mechanical debridement when it is removed at the next dressing change. It is a common method of mechanical debridement.
A nurse is documenting data about a healing wound on a patient's lower leg. The predominant exudate in the wound is watery in consistency and light red in color. The nurse should document this exudate as:
-This exudate is serosanguineous, which is this and watery in consistency and pink to light red in color.
A nurse assessing a pressure ulcer over a patient's right heel area observes a deep crater with no eschar or slough and no exposed muscle or bone. The nurse should document that this patient has a pressure ulcer that is...
-A stage III pressure ulcer has full-thickness tissue loss appearing as a deep crater, without exposed muscle or bone. There may or may not be slough. This patient's wound fits this description.
A nurse is documenting data about a deep necrotic wound on a patient's left buttock. The nurse observes a yellowish-tan, soft, stringy area of necrotic tissue formed in clumps and adhering firmly to the wound bed. The nurse should document this type of necrotic tissue as:
-Slough is stringy and whitish, yellowish, and/or tan necrotic tissue that is firmly attached to the wound bed. This is the correct term for the tissue the nurse has observed.
A patient who has a full-thickness wound continues to experience considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes?
-In general, keeping some moisture within a wound reduces pain. Hydrogel dressings work by maintaining a moist wound environment, so they are a good choice for helping to reduce the pain associated with dressing changes.
A nurse is caring for a patient who is admitted with multiple wounds sustained in a motor-vehicle crash. Understanding the patient's specific needs during this initial stage of wound healing, the nurse should incorporate which of the following into the patient's plan of care to prevent a prolongation of this phase?
Apply oxygen at 2 L/min via nasal cannula.
-Following an acute injury, the body responds by increasing perfusion to the location of the injry during the inflammatory phase of wound healing. The purpose of this increased blood supply to the wounds is to transport the oxygen and nutrients essential for healing. It is common to see a delay in the resolution of the inflammatory phase of chronic wounds in patients who have a a lack of oxygen or poor perfusion.
- Introduce yourself
- Confirm client (2 identifiers)
- Verify orders & allergies
- Gather supplies
- Assess Pain (PQRST)
- administer prescribed pain medication 3060 minutes beforehand as needed.