The nurse is completing a head-to-toe assessment and notices a wound on the patient's trochanter. The patient winces when the area is palpated, and there is minimal slough with visible subcutaneous tissue. How should the nurse stage this wound?
Stage 1 pressure ulcer
Stage 4 pressure ulcer
Stage 2 pressure ulcer
Stage 3 pressure ulcer
The Correct Answer is D
Rationale:
A. A Stage 1 pressure ulcer is characterized by intact skin with non-blanchable redness; it does not involve any tissue loss or visible subcutaneous tissue, which is present in this case.
B. A Stage 4 pressure ulcer involves full-thickness tissue loss with exposed bone, muscle, or tendon; while this wound has visible subcutaneous tissue, it does not exhibit the depth or extent associated with Stage 4.
C. A Stage 2 pressure ulcer is defined by partial-thickness skin loss involving the epidermis and possibly the dermis, presenting as a blister or abrasion. This wound shows more depth and visible subcutaneous tissue, which indicates it is deeper than a Stage 2.
D. A Stage 3 pressure ulcer involves full-thickness skin loss, with visible fat and possible slough. The presence of minimal slough and visible subcutaneous tissue in this wound aligns with the characteristics of a Stage 3 ulcer.
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View Related questions
Correct Answer is B
Explanation
Rationale:
A. Stating that the phase cannot be determined is incorrect because the wound presents clear signs indicative of a healing phase.
B. The inflammatory phase of healing typically lasts for 3 to 5 days post-injury and is characterized by redness, swelling, warmth, and pain due to the body’s response to injury. The lack of slough or drainage, along with surrounding tissue swelling and pain, aligns with the inflammatory phase.
C. The proliferative phase follows the inflammatory phase and involves the formation of new tissue and the development of granulation tissue, which is not yet apparent in Mr. Jones's wound.
D. The maturation phase occurs after the proliferative phase, focusing on the strengthening and reorganization of collagen, which is not relevant as the wound is still in the inflammatory stage.
Correct Answer is B
Explanation
Rationale:
A. Emptying the pouch when it becomes 1/3 full is appropriate and helps prevent leakage and odor. This statement shows understanding of proper pouch management.
B. Enteric-coated medications can be problematic for clients with an ileostomy as they may not dissolve properly in the digestive system, potentially leading to decreased absorption. The client should be aware that these medications may not be suitable for their condition.
C. Changing the entire pouch system at least weekly is a common recommendation to maintain hygiene and skin integrity. This indicates the client understands the need for regular pouch maintenance.
D. Caution when eating high-fiber foods is important, as these foods can cause blockages in the ileostomy. This statement reflects the client’s awareness of dietary considerations for managing their ileostomy.