Asked by Joseph Yniguez on Jun 14, 2024

verifed

Verified

The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient?

A) Partial-thickness wound repair
B) Full-thickness wound repair
C) Primary intention
D) Tertiary intention

Stage IV Pressure Ulcer

A severe pressure injury characterized by extensive damage to muscle, bone, or supporting structures under visible skin loss.

Full-Thickness Wound Repair

A medical procedure to close wounds where all layers of the skin and sometimes underlying tissues are involved, requiring more complex closures.

Tertiary Intention

A wound healing process where the wound is intentionally left open due to infection or contamination and is closed later by surgical intervention after the infection has been controlled.

  • Prioritize nursing care for patients with different stages of pressure ulcers.
verifed

Verified Answer

CL
Ceora LesureJun 19, 2024
Final Answer :
B
Explanation :
Stage IV pressure ulcers are full-thickness wounds that extend into the dermis and heal by scar formation because the deeper structures do not regenerate, hence the need for full-thickness repair. The full-thickness repair has four phases: hemostasis, inflammatory, proliferative, and maturation. A wound heals by primary intention when wounds such as surgical wounds have little tissue loss; the skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until risk of infection is resolved.