Wound Care Techniques and Interventions
Wound Care Techniques and Interventions ( 4 Questions)
A client is admitted to the hospital with a diabetic foot ulcer. The nurse notes that the wound has a black, dry, and hard eschar covering most of its surface. Which action should the nurse take?
This is not an appropriate intervention, as wet-to-dry dressings are not recommended for wounds with dry eschar, as they can cause trauma and bleeding to healthy tissue. Wet-to-dry dressings are used for wounds with moist necrotic tissue or slough that needs to be removed.
This is not an appropriate intervention, as transparent film dressings are not indicated for wounds with necrotic tissue or infection. Transparent film dressings are used for wounds with minimal drainage that need protection from external contamination and moisture loss.
This is not an appropriate intervention, as leaving the wound open to air without any dressing can expose it to further trauma and infection. Wounds need to be covered with an appropriate dressing that maintains a moist environment and supports wound healing.
Rationale: The nurse should consult with the provider about surgical debridement for a wound that has a black, dry, and hard eschar covering most of its surface. This type of eschar indicates necrotic tissue that impairs wound healing and increases the risk of infection. Surgical debridement is the most effective method of removing large amounts of necrotic tissue from a wound.
Correct answer: D) Consult with the provider about surgical debridement.
Rationale: The nurse should consult with the provider about surgical debridement for a wound that has a black, dry, and hard eschar covering most of its surface. This type of eschar indicates necrotic tissue that impairs wound healing and increases the risk of infection. Surgical debridement is the most effective method of removing large amounts of necrotic tissue from a wound.
Incorrect options:
A) Debride the wound using wet-to-dry dressings. - This is not an appropriate intervention, as wet-to-dry dressings are not recommended for wounds with dry eschar, as they can cause trauma and bleeding to healthy tissue. Wet-to-dry dressings are used for wounds with moist necrotic tissue or slough that needs to be removed.
B) Cover the wound with a transparent film dressing. - This is not an appropriate intervention, as transparent film dressings are not indicated for wounds with necrotic tissue or infection. Transparent film dressings are used for wounds with minimal drainage that need protection from external contamination and moisture loss.
C) Leave the wound open to air without any dressing. - This is not an appropriate intervention, as leaving the wound open to air without any dressing can expose it to further trauma and infection. Wounds need to be covered with an appropriate dressing that maintains a moist environment and supports wound healing.