The nurse prepares to apply a dressing for a patient who has a full-thickness wound with moderate exudate and necrosis. Which is the best nursing intervention to help the patient achieve an expected long-term outcome for this wound?

Question

a. Assess the wound for sinus tracts and tunneling.
b. Maintain oxygenation with supplemental oxygen.
c. Pack the wound lightly with a wet-to-dry dressing.
d. Provide a well-balanced diet with high-quality protein.

Answer 1

D
Improving the patient's nutrition is imperative for wound healing. A well-balanced diet with high-quality protein is required 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 promote granulation tissue, tissue growth, and wound closure. Assessing the wound for sinus tracts and tunneling is most important at the beginning of wound care to provide a compre-hensive plan. The importance of this assessment 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. Initially the patient 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. The need for supplemental oxygen for healing should diminish as healing progresses and a new vascular bed forms that delivers adequate oxygen to the region. 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 débridement and risks damaging granulation tissue in the wound bed.