Question

An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding?

Answer 1

Bright red tissue at the venous stasis ulcer site after removing the Unna boot indicates the presence of granulation tissue, a sign of wound healing. The nurse should assess for other signs of healing and monitor for signs of infection. If signs of infection are present, the healthcare provider should be notified for further evaluation and possible treatment.

Step-by-step explanation:

When the nurse observes bright red tissue at the venous stasis ulcer site after removing the Unna boot, it indicates the presence of granulation tissue. Granulation tissue is a sign of the wound healing process, as it consists of new blood vessels and connective tissue.

The nurse should assess the wound for other signs of healing, such as decreased size, absence of drainage, and formation of healthy granulation tissue. If the wound is progressing in a positive manner and the client has no complications, the nurse should continue with the established plan of care.

However, if the nurse observes any signs of infection, such as increased pain, swelling, warmth, or pus-like drainage, it is important to notify the healthcare provider for further evaluation and possible antibiotic treatment.