The nurse observes eschar at the base of a client's stage IV pressure ulcer while preparing to apply a hydrocolloid dressing. Which should the nurse implement?
1. Remove the eschar with a sterile forceps and scissors.
2. Fill the base of the client's ulcer with a silicone lotion.
3. Place the hydrocolloid dressing directly over the eschar.
4. Place transparent dressing over the hydrocolloid dressing.
1
1 and 3. If the nurse applies the dressing over eschar, the dressing effectively seals the necrotic tissue onto the wound bed. The nurse applies basic principles of wound care and removes the eschar before applying the hydrocolloid dressing to decrease the risk of infection and promote wound healing. To avoid contaminating the site, the nurse uses sterile instruments because removing the eschar exposes fresh tissue.
2. Silicone lotion is contraindicated for use in a large crater.
4. A hydrocolloid dressing creates its own seal; thus, the nurse avoids using a trans-parent dressing over the hydrocolloid dressing.
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