The nurse is changing the dressing of a patient with a stage IV pressure injury. Upon removal of the gauze dressing, the nurse notes the wound bed appears dry. The wound bed is clear of slough or eschar. The nurse cleans and measures the wound. Which of the following is the best wound care strategy for this patient?

Apply wound filler and cover with a hydrocolloid dressing. In order for a wound to heal, the wound must be kept moist at all times to promote the formation of granulation tissue. A dry wound will not heal appropriately. Therefore, the current dressing regimen is inappropriate. Of the above options, the most appropriate wound care strategy is to apply a wound filler to obliterate the dead space and cover it with a hydrocolloid dressing to form an occlusive barrier to keep in moisture. Povidone-iodine can be used for wound debridement and initially for wound cleansing. However, because this patient’s wound is clear of slough and eschar, it does not require debridement. Alginate sheets should not be applied to dry or minimally draining wounds since they can cause dehydration and delay wound healing.

The nurse is changing the dressing of a patient with a stage IV p...

Category: Physiological Adaptation
Difficulty: 7

Topics: Communication & Documentation

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