The nurse prepares to apply a wet-to-dry dressing for the client who has a full-thickness wound with moderate exudate and necrosis. Which is the best nursing intervention to achieve an ex-pected long-term outcome for this wound?
1. Assess the wound for sinus tracts and tunneling.
2. Maintain oxygenation with supplemental oxygen.
3. Pack the wound lightly with a wet-to-dry dressing.
4. Provide well-balanced diet with high-quality protein.
4
4. The most important intervention to achieve an expected long-term outcome for this client's wound is providing a well-balanced diet with high-quality protein to maintain an adequate supply of substrate for wound healing. Initially, the nurse performs wound care to remove exudate and necrotic tissue; during this time, good nutrition is important to begin tissue repair. After this, the purpose of the dressing changes is to promoting granulation tissue, tissue growth, and wound closure. Good nutrition for healing is critical to sustain the client's ability to meet these challenges over time be-cause the client's nutritional requirements continue until wound closure is complete.
1. Assessing the wound for sinus tracts and tunneling is most important at the begin-ning of wound care to provide a comprehensive plan. This assessment's importance diminishes over time as the wound granulates and decreases in size; however, the nurse continues to assess the wound frequently, evaluate care, and plan suitable nursing care and dressing changes to suit the phase of healing.
2. Initially, the client needs supplemental oxygen to facilitate wound healing because regional tissue perfusion and oxygenation are inadequate to sustain cell metabolism and promote tissue growth and repair; therefore, the client receives supplemental oxygen to saturate the blood, providing optimal tissue oxygenation in the face of im-paired perfusion. The need for supplemental oxygen for healing should diminish as healing progresses and a new vascular bed forms delivering adequate oxygen to the region.
3. The nurse should not pack the wound using a wet-to-dry dressing after eliminating the exudate and necrotic tissue because a wet-to-dry dressing is nonselective de-bridement and risks damaging granulation tissue in the wound bed. The nurse chooses a dressing to facilitate wound healing suitable for each phase of healing.
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When assessing a client, the nurse notes edema over the tibia that leaves a 4 mm indentation in the skin. The nurse appropriately documents this finding as:
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The nurse is teaching a class for patients who have been recently diagnosed with epilepsy. The nurse determines that learning has occurred when the patients make which statements?
1. "Excessive stress levels cause disruptions in how the brain receives oxygen, leading to epilepsy." 2. "Epilepsy may be caused by a head injury." 3. "Eating disorders, like anorexia nervosa, increase the risk for developing epilepsy." 4. "A stroke, or brain attack, could increase the risk for developing epilepsy." 5. "With some cases of epilepsy, the cause is never determined."