Question

The nurse uses the RYB wound classification system to assess the wound of a client who cut his arm on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound?

a.Irrigate the wound.
b.Provide gentle cleansing of the wound.
c.Débride the wound.
d.Change the dressing frequently.

Answer 1

A nurse using the RYB classification system has documented a wound as 'red', indicating it is in the proliferative phase of healing and the priority is gentle cleansing to facilitate healing and protect new tissue.

Step-by-step explanation:

Using the RYB wound classification system, if a nurse documents a wound as 'red', the priority nursing intervention for this type of wound is to provide gentle cleansing of the wound. This intervention is key because a red wound is in the proliferative phase of healing, which means the focus is on protecting new tissue and fostering a healing environment. Interventions such as irrigation or debridement are not typically indicated for red wounds unless there is evidence of a significant bioburden or infection. Changing dressings should be done as needed, considering the amount of wound exudate and the recommendations for the specific dressing type used. It is essential for a nurse to monitor the wound closely for signs of infection, which include increased redness, swelling, and pain.