A frail, older adult home health patient who had chickenpox as a child has been exposed to varicella (chickenpox) several days ago. What should the nurse do?

A. Increase the effectiveness of the skin graft:

Debridement can indeed increase the effectiveness of a skin graft by preparing a clean, viable wound bed for grafting. Removing dead tissue and debris helps the skin graft adhere to healthy tissue and promotes successful graft take. However, this is not the primary purpose of debridement.

B. Promote movement in the affected area:

While debridement can indirectly contribute to promoting movement by improving wound healing and reducing pain, the primary purpose of debridement is not to promote movement in the affected area.

C. Prevent infection and promote healing:

This statement accurately reflects the primary purpose of debridement. By removing nonviable tissue, debris, and foreign material from the wound, debridement helps prevent infection by reducing the bacterial load and creating an environment conducive to healing. It also promotes granulation tissue formation and wound contraction, which are essential for wound healing.

D. Promote suppuration of the wound:

Suppuration refers to the formation and discharge of pus from a wound, often indicating infection. Debridement aims to remove necrotic tissue and prevent infection, so promoting suppuration is not a desired outcome of debridement.

A. Intact skin with nonblanchable redness, painful, warm, soft localized area over a bony prominence

Stage 1 pressure injuries are characterized by intact skin with nonblanchable redness over a localized area, typically over a bony prominence like the sacrum, heel, or elbow. The skin may feel painful, warm, and soft to the touch. Nonblanchable redness means that when pressure is applied to the area, the redness does not fade or blanch (turn white). This stage indicates that tissue damage has occurred, but the skin is still intact.

B. Shallow, open, shiny, dry injury, pink-red wound bed without sloughing or bruising: This description is more indicative of a Stage 2 pressure injury, which involves partial-thickness skin loss with an intact or ruptured blister. The wound bed is usually pink or red, and there is no sloughing or bruising.

C. Full-thickness tissue loss, slough and black eschar in wound bed with undermining and tunneling: This description corresponds to a Stage 3 or Stage 4 pressure injury. Stage 3 involves full-thickness tissue loss with visible subcutaneous fat but no bone, tendon, or muscle exposed. Stage 4 involves extensive tissue loss with exposure of bone, tendon, or muscle. Both stages may include slough (yellow or white tissue) and black eschar (hard, necrotic tissue), along with undermining (tissue destruction under intact skin edges) and tunneling (narrow passageways extending from the wound).

D. Full-thickness tissue loss, subcutaneous fat visible, possible undermining and tunneling: This description also corresponds to a Stage 3 pressure injury, as it involves full-thickness tissue loss with visible subcutaneous fat. The mention of possible undermining and tunneling further suggests a Stage 3 pressure injury.