Question

A client has a wound on his left trochanter that is 4 inches in diameter, with black tissue at the perimeter, and bone is exposed. Which is the nurse's best action?

A. Document as a stage I pressure ulcer and apply a transparent dressing.
B. Document as a stage II pressure ulcer and start wet-to-dry gauze treatments.
C. Document as a stage IV pressure ulcer and prepare the client for débridement.
D. Document as a stage III pressure ulcer and start antibiotic therapy.

Answer 1

The nurse's best action for a pressure ulcer with a 4-inch diameter, black tissue, and exposed bone is to document as a stage IV ulcer and prepare for debridement.

Step-by-step explanation:

The case described involves a wound with a 4-inch diameter, black tissue at the perimeter, and exposed bone on the client's left trochanter. The appropriate nursing action would be to document the wound as a stage IV pressure ulcer and prepare the client for debridement. Stage IV pressure ulcers are characterized by full-thickness tissue loss with exposed bone, tendon, or muscle, and often include slough or eschar on part of the wound. These ulcers can extend into muscle and/or supporting structures, making osteomyelitis or osteitis possible. Immediate and aggressive action is required to manage the wound, including surgical debridement to remove devitalized tissue, potentially followed by additional therapies such as antibiotic treatment, depending on the infection status and other individual patient factors. It is not correct to classify this wound as stage I, II, or III due to its severity, and treatments such as transparent dressings or wet-to-dry gauze treatments are not adequate for such advanced ulcers.

The nurse's best action would be to document the wound as a stage IV pressure ulcer and prepare the client for débridement.

A stage IV pressure ulcer is the most severe stage, characterized by extensive tissue damage, with visible bone, tendon, or muscle. The presence of black tissue at the perimeter indicates necrotic tissue, which needs to be removed through débridement, a process of removing dead or infected tissue from a wound. This will promote healing and prevent further infection. Once the débridement is done, the wound can be dressed appropriately to aid in the healing process.

Starting antibiotic therapy alone, as suggested in option D, would not be sufficient to address the severity of the wound and the underlying tissue damage. Option A and B are incorrect as they do not recognize the severity of the wound and the need for débridement.