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Assessment of Skin Integrity and Wound Characteristics
Assessment of Skin Integrity and Wound Characteristics ( 3 Questions)
A nurse is assessing a client with a pressure ulcer on the sacrum. Which finding indicates a potential complication of the wound?
This is a normal finding, as serous drainage is clear and watery and indicates fluid leakage from damaged capillaries.
This is a normal finding, as erythema (redness) around the wound edges indicates inflammation and increased blood flow to the area, which are part of the normal healing process.
Rationale: Foul odor from the wound may indicate an infection or necrotic tissue, which can impair wound healing and increase the risk of sepsis. The nurse should notify the provider and obtain a wound culture if indicated.
This is a normal finding, as granulation tissue is pink or red and indicates new tissue growth and blood vessel formation in the wound.
Correct answer: C) Foul odor from the wound
Rationale: Foul odor from the wound may indicate an infection or necrotic tissue, which can impair wound healing and increase the risk of sepsis. The nurse should notify the provider and obtain a wound culture if indicated.
Incorrect options:
A) Serous drainage from the wound - This is a normal finding, as serous drainage is clear and watery and indicates fluid leakage from damaged capillaries.
B) Erythema around the wound edges - This is a normal finding, as erythema (redness) around the wound edges indicates inflammation and increased blood flow to the area, which are part of the normal healing process.
D) Granulation tissue in the wound bed - This is a normal finding, as granulation tissue is pink or red and indicates new tissue growth and blood vessel formation in the wound.