The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this patient includes
a. Monitoring of the wound.
b. Irrigation of the wound.
c. Débridement of the wound.
d. Management of drainage.
C
Débridement is the removal of nonviable necrotic tissue. Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base for healing. A wound will not move through the phases of healing if the wound is infected. Irrigating the wound with noncytotoxic cleaners will not damage or kill fibroblasts and healing tissue and will help to keep the wound clean once débrided. When treating a pressure ulcer, it is important to monitor and reassess the wound at least every 8 hours. Management of drainage will help keep the wound clean.
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A. teach the patient to pivot to the chair. B. lift the patient into the chair. C. slide the patient from the bed to the chair. D. pull the patient on a sheet.