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Documentation and Evaluation of Wound Care
Documentation and Evaluation of Wound Care ( 3 Questions)
A nurse is assessing a client who has a pressure ulcer on the sacrum. Which finding should the nurse report to the wound care specialist?
This is not a reportable finding, as foul odor may be present in some wounds without infection, especially if the wound is colonized by anaerobic bacteria. However, the nurse should monitor the wound for other signs of infection, such as increased pain, redness, swelling, or fever.
Rationale: The wound has a yellowish-green drainage, which indicates infection and possible necrosis of the wound tissue. This finding should be reported to the wound care specialist for further evaluation and treatment.
This is not a reportable finding, as granulation tissue is a sign of healing and indicates that new blood vessels and connective tissue are forming in the wound bed.
This is not a reportable finding, as partial-thickness skin loss is consistent with the definition of a pressure ulcer, which is a localized injury to the skin and/or underlying tissue due to pressure or shear.
Correct answer: B) The wound has a yellowish-green drainage.
Rationale: The wound has a yellowish-green drainage, which indicates infection and possible necrosis of the wound tissue. This finding should be reported to the wound care specialist for further evaluation and treatment.
Incorrect options:
A) The wound has a foul odor. - This is not a reportable finding, as foul odor may be present in some wounds without infection, especially if the wound is colonized by anaerobic bacteria. However, the nurse should monitor the wound for other signs of infection, such as increased pain, redness, swelling, or fever.
C) The wound has a granulation tissue in the base. - This is not a reportable finding, as granulation tissue is a sign of healing and indicates that new blood vessels and connective tissue are forming in the wound bed.
D) The wound has a partial-thickness skin loss. - This is not a reportable finding, as partial-thickness skin loss is consistent with the definition of a pressure ulcer, which is a localized injury to the skin and/or underlying tissue due to pressure or shear.