Asked by Tiffany Wisham on May 07, 2024
Verified
The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next\bold{next}next step will the nurse anticipate?
A) Monitor the wound.
B) Document the wound.
C) Debride the wound.
D) Manage drainage from wound.
Debride Wound
The process of removing dead, damaged, or infected tissue from a wound to help healing.
Black Ulcer
A type of skin ulcer characterized by its dark coloration, often resulting from necrosis or dead tissue.
Pressure Ulcer
Injury to skin and underlying tissue resulting from prolonged pressure on the skin.
- Develop skills in proficient communication and apply nursing practices for managing wound care.
Verified Answer
NJ
Najla JosephMay 08, 2024
Final Answer :
C
Explanation :
Debridement is the removal of nonviable necrotic (black) tissue. Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base for healing. A wound will not move through the phases of healing if the wound is infected. Documentation occurs after completion of skill. When treating a pressure ulcer, it is important to monitor and reassess the wound at least every 8 hours. Management of drainage will help keep the wound clean, but that is not the next step.
Learning Objectives
- Develop skills in proficient communication and apply nursing practices for managing wound care.
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