The nurse assesses the patient's pressure ulcer after 2 weeks of ambulatory wound care and observes pink tissue at the base of the wound.Which should the nurse implement?

Question

Quizplus · Accepted Answer

Pink tissue in the wound base is consistent with clinical indicators of granulation tissue; thus the nurse recommends using a hydrocolloid dressing to maintain a moist environment and protect the wound base because a moist environment facilitates healing.The appearance of granulation tissue indicates that the patient's wound is healing.Unless the patient requests nutritional counseling,it is not indicated.The wound does not contain cellular debris or necrotic tissue; thus débridement is not indicated.The wound does not have clinical indicators of infection,which would include exudate and foul odor.

The Nurse Assesses the Patient's Pressure Ulcer After 2 Weeks