The nurse prepares to perform a dressing change. Which does the nurse apply to implement general nursing interventions for dressing changes?

Question

1. Pack the dead space in an ulcer tightly.
2. Debride a wound with dry gauze dressing.
3. Keep the wound edges dry and ulcer moist.
4. Dry wound bed to stimulate granular tissue.

Answer 1

3
3 and 4. The nurse maintains clean, dry skin surrounding a wound but keeps the wound bed moist to promote healing because a moist wound bed stimulates forma-tion of granulation tissue. Although the goal is to keep the surrounding skin dry, the nurse avoids drying the skin and, thus, hydrates the client and protects the skin to maintain its moisture content. Skin exposed to moisture frequently, especially if con-taminated with urine or feces, has a high risk of impaired tissue integrity.
1. The nurse packs dead space in a wound lightly to absorb exudate.
2. The purpose of a dry dressing is protection for wounds with minimal drainage. Dry dressings do not interface with the wound and debridement uses a wet-to-dry dress-ing. If exudate saturates a dry dressing, the nurse removes and changes it quickly or reinforces it.