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Special Considerations in Wound Care
Special Considerations in Wound Care ( 3 Questions)
A nurse is assessing a client with a pressure ulcer on the sacrum. Which finding should the nurse report to the provider immediately?
Rationale: The wound with a foul odor and purulent drainage indicates an infection, which can delay healing and cause systemic complications, such as sepsis. The nurse should report this finding to the provider immediately and obtain a wound culture and sensitivity test.
The wound has a black, necrotic tissue in the center. - This indicates eschar, which is dead tissue that needs to be debrided to promote healing. However, this is not an urgent finding and can be addressed by the wound care team.
This indicates healthy tissue formation and healing. This is a positive finding and does not need to be reported.
The wound has a yellow, sloughing tissue on the surface. - This indicates fibrin, which is a protein that forms during inflammation and can impede healing. The nurse should remove this tissue by irrigation or debridement, but this is not an urgent finding.
Correct answer: A) The wound has a foul odor and purulent drainage.
Rationale: The wound with a foul odor and purulent drainage indicates an infection, which can delay healing and cause systemic complications, such as sepsis. The nurse should report this finding to the provider immediately and obtain a wound culture and sensitivity test.
Incorrect options:
B) The wound has a black, necrotic tissue in the center. - This indicates eschar, which is dead tissue that needs to be debrided to promote healing. However, this is not an urgent finding and can be addressed by the wound care team.
C) The wound has a red, granulating tissue at the edges. - This indicates healthy tissue formation and healing. This is a positive finding and does not need to be reported.
D) The wound has a yellow, sloughing tissue on the surface. - This indicates fibrin, which is a protein that forms during inflammation and can impede healing. The nurse should remove this tissue by irrigation or debridement, but this is not an urgent finding.