More Questions on This Topic
More Questions on This Topic ( 10 Questions)
A client is admitted to the hospital with a diabetic foot ulcer. The nurse notes that the wound has black, dry, and hard tissue covering most of the wound bed. How should the nurse document this finding?
Rationale: Eschar is dead tissue that is black, dry, and hard and adheres firmly to the wound bed or ulcer edges. It may be stable (dry, adherent, intact without erythema or fluctuance) or unstable (loose, moist, boggy, edematous). Stable eschar on the heels serves as the body's natural cover and should not be removed. Unstable eschar in infected wounds should be debrided to expose viable tissue.
This is dead tissue that is yellow, tan, gray, green, or brown and has a moist, stringy, or mucinous appearance. It may be loosely attached or firmly adherent to the wound bed. It should be removed to promote wound healing.
This is a protein involved in blood clotting that forms a mesh-like structure to seal the wound and stop bleeding. It may appear as a yellowish-white film on the wound surface. It should not be confused with slough or pus.
This is fluid that leaks out of blood vessels into the surrounding tissues due to inflammation or injury. It may have different characteristics depending on the type and stage of the wound. It should be managed to maintain a moist but not wet wound environment.
Correct answer: A) Eschar
Rationale: Eschar is dead tissue that is black, dry, and hard and adheres firmly to the wound bed or ulcer edges. It may be stable (dry, adherent, intact without erythema or fluctuance) or unstable (loose, moist, boggy, edematous). Stable eschar on the heels serves as the body's natural cover and should not be removed. Unstable eschar in infected wounds should be debrided to expose viable tissue.
Incorrect options:
B) Slough - This is dead tissue that is yellow, tan, gray, green, or brown and has a moist, stringy, or mucinous appearance. It may be loosely attached or firmly adherent to the wound bed. It should be removed to promote wound healing.
C) Fibrin - This is a protein involved in blood clotting that forms a mesh-like structure to seal the wound and stop bleeding. It may appear as a yellowish-white film on the wound surface. It should not be confused with slough or pus.
D) Exudate - This is fluid that leaks out of blood vessels into the surrounding tissues due to inflammation or injury. It may have different characteristics depending on the type and stage of the wound. It should be managed to maintain a moist but not wet wound environment.