A patient presents to the wound care clinic for treatment of a right heel ulcer. On assessment, the nurse notes the wound bed to be beefy red and without exudate

Question

Which of the following wound care regimens would be most appropriate for the patient? 1. an enzymatic debridement agent used daily
2. a wet-to-moist dressing changed twice daily
3. whirlpool treatments once daily
4. wllow the wound to remain open to air

Answer 1

2

Rationale: Wet-to-damp gauze dressings provide a moist wound environment and are used for the mechanical debridement of red or yellow wounds. Continuous moist dressings can be used for the protection of red wounds. Epithelialization is enhanced by a moist environment. An enzymatic debridement agent used daily is incorrect because enzymatic debridement agents are topical enzymes that are applied to necrotic areas. The nurse would not want to apply such agents to a beefy red wound bed that contains no exudate. Whirlpool treatments once daily are incorrect because whirlpool treatments would not be indicated for the beefy red wound bed that is without exudate. Allowing the wound to remain open to air could increase the risk for infection. Because the skin integrity is disrupted, the body has lost its primary defense against infection.