The nurse is providing health teaching to a client with a wound. Which of the following should be included in the teaching?
Adequate nutrition delays wound healing and increases risk of infection.
Chronic wounds heal better in a dry, open environment so leave them open to air.
Fat tissue heals more rapidly because there is less vascularization.
Long term steroid use diminishes the inflammatory response and delays wound healing.
The Correct Answer is D
Rationale:
A. Adequate nutrition actually promotes wound healing. Poor nutrition, especially a lack of protein and vitamins, delays healing and increases the risk of infection.
B. Chronic wounds heal better in a moist environment rather than a dry one. Moist wound healing promotes cell migration and prevents scab formation, improving healing.
C. Fat tissue does not heal more rapidly. In fact, it heals more slowly due to decreased vascularization, which impairs oxygen delivery and nutrient supply to the tissue.
D. Long-term steroid use diminishes the body’s inflammatory response, reducing the body's ability to initiate the healing process. This delay in inflammation can lead to slower wound healing and a higher risk of infection.
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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.
Correct Answer is D
Explanation
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.