The nurse assesses the patient's pressure ulcer and notes tissue maceration around the wound. Which action does the nurse take to address this issue?

Question

a. Eliminates dead space
b. Uses a skin barrier
c. Applies a foam dressing
d. Obtains a wound culture

Answer 1

B
Macerated skin around a wound is consistent with tissue exposure to irritating agents or moisture. The nurse cleanses the area gently and applies a moisture barrier to protect the skin. Although skin needs moisture and a moist environment facilitates wound healing, frequent exposure to moisture or other agents that strip the skin of surface protection increases the risk of skin break-down. Examples of such agents would be urine or feces, especially diarrhea. Macerated skin has no dead space. Moderate-to-heavy exudate is an indication for a foam dressing. A wound culture is not indicated because macerated tissue is not necessarily infected.