Asked by Stephanie Pelaez on Jun 14, 2024
Verified
A patient had a CVA (stroke) 2 days ago,resulting in decreased mobility to her left side.During the assessment,the nurse discovers a stage I pressure area on the patient's left heel.What is the initial treatment for this pressure ulcer?
A) Antibiotic treatment for 2 weeks
B) Normal saline irrigation of the ulcer daily
C) Debridement to the left heel
D) Elevation of the left heel off the bed
Stage I Pressure Area
The earliest stage of pressure ulcer development, characterized by red, unbroken skin that does not blanch with pressure.
CVA (Stroke)
A medical condition characterized by rapid loss of brain function due to a disturbance in the blood supply to the brain, known as cerebral vascular accident.
Normal Saline Irrigation
A medical procedure involving the flushing of body tissues with a solution of sodium chloride to clean wounds or clear nasal passages.
- Identify underlying causes and risk conditions for the occurrence of pressure ulcers.
- Choose the right interventions and types of dressings for wound care, based on the particular traits of the wound.
Verified Answer
IP
Infinite ParadoxJun 21, 2024
Final Answer :
D
Explanation :
Pressure ulcers are caused by pressure to an area that restricts blood flow,causing ischemia to underlying tissue.The primary treatment is to relieve the pressure,thus improving blood flow.Elevating the patient's left heel off the bed would relieve pressure to this area.Antibiotics treat infection; a stage I pressure injury is not infected.Skin of a stage I pressure wound is intact but has nonblanchable redness; therefore,irrigation is not indicated for stage I pressure wounds.The area may be painful,firm,soft,or warmer or cooler as compared with adjacent tissue,but is not deep enough for debridement.
Learning Objectives
- Identify underlying causes and risk conditions for the occurrence of pressure ulcers.
- Choose the right interventions and types of dressings for wound care, based on the particular traits of the wound.