Question

Which intervention should the nurse include in the plan of care for a patient who is paraplegic with a stage 3 pressure injury?

Keep the pressure injury clean and dry.
Maintain protein intake of at least 1.25 g/kg/day.
Use a 10-mL syringe to irrigate the pressure injury.
Irrigate the pressure injury with hydrogen peroxide.

Answer 1

For a paraplegic patient with a stage 3 pressure injury, the nurse should keep the wound clean and dry and ensure adequate protein intake for healing. Avoid using hydrogen peroxide for irrigation, as it can damage new tissues.

Step-by-step explanation:

For a patient who is paraplegic with a stage 3 pressure injury, an appropriate plan of care should include interventions that promote healing and prevent further tissue damage. One essential intervention is to keep the pressure injury clean and dry to prevent infection and promote a suitable environment for wound healing. Additionally, it is important to maintain protein intake of at least 1.25 g/kg/day, as adequate protein is crucial for repair of tissues and recovery. However, the use of hydrogen peroxide for irrigation should generally be avoided because it can damage new tissue growth. Instead, saline or prescribed wound cleansers are often recommended for wound irrigation to gently wash away debris without harming the new tissue. In the case of Mark, who has rapidly deteriorating symptoms and the appearance of necrotic tissue, immediate medical assessment and intervention are necessary to address potential complications such as sepsis.