Documentation and Evaluation of Wound Care
Documentation and Evaluation of Wound Care ( 3 Questions)
A nurse is evaluating a client's progress after receiving hyperbaric oxygen therapy (HBOT) for a chronic venous ulcer. Which outcome indicates that HBOT has been effective?
This is not an outcome that indicates HBOT effectiveness, as pain reduction may be due to other factors, such as analgesics, compression therapy, or elevation of the leg. Pain is also not a reliable indicator of wound healing, as some wounds may heal without pain or have persistent pain despite healing.
This is not an outcome that indicates HBOT effectiveness, as oxygen saturation in the blood reflects systemic oxygenation and does not necessarily correlate with tissue oxygenation. Oxygen saturation may also vary depending on factors such as hemoglobin level, cardiac output, or ventilation-perfusion mismatch.
This is not an outcome that indicates HBOT effectiveness, as edema reduction may be due to other factors, such as compression therapy, diuretics, or elevation of the leg. Edema is also not a reliable indicator of wound healing, as some wounds may heal with edema or have persistent edema despite healing.
Rationale: The client has increased granulation tissue in the ulcer, which indicates that HBOT has been effective in enhancing wound healing. HBOT delivers 100% oxygen at high pressure to increase oxygen delivery and diffusion to hypoxic tissues, stimulating angiogenesis, collagen synthesis, and fibroblast proliferation.
Correct answer: D) The client has increased granulation tissue in the ulcer.
Rationale: The client has increased granulation tissue in
the ulcer, which indicates that HBOT has been effective in enhancing wound healing. HBOT delivers 100% oxygen at high pressure to increase oxygen delivery and diffusion to hypoxic tissues, stimulating angiogenesis, collagen synthesis, and fibroblast proliferation.
Incorrect options:
A) The client reports reduced pain in the affected leg. - This is not an outcome that indicates HBOT effectiveness, as pain reduction may be due to other factors, such as analgesics, compression therapy, or elevation of the leg. Pain is also not a reliable indicator of wound healing, as some wounds may heal without pain or have persistent pain despite healing.
B) The client has increased oxygen saturation in the blood. - This is not an outcome that indicates HBOT effectiveness, as oxygen saturation in the blood reflects systemic oxygenation and does not necessarily correlate with tissue oxygenation. Oxygen saturation may also vary depending on factors such as hemoglobin level, cardiac output, or ventilation-perfusion mismatch.
C) The client has decreased edema in the affected leg. - This is not an outcome that indicates HBOT effectiveness, as edema reduction may be due to other factors, such as compression therapy, diuretics, or elevation of
the leg. Edema is also not a reliable indicator of wound healing, as some wounds may heal with edema or have persistent edema despite healing.