The nurse is caring for a client who failed to meet the outcome of healing of a stage 2 pressure injury over the coccyx. Which should the nurse identify as a likely contributing factor?
A)The rubber doughnut pressure relief device was not delivered by central supply.
B)The client's serum albumin increased over the last month.
C)A right side-back-left side-back turning schedule was used.
D)Nurses did not document disinfection of the wound with alcohol at each dressing change.

Question

Quizplus · Accepted Answer

A)Of the options listed, the only one that would result in poor healing is the right side-back-left side-back turning schedule. This schedule places the client on the back 50% of the time, which is where the ulcer is located. There are six possible body positions when preventing or treating a pressure ulcer, and these positions should be used equally. The nurse should be careful to minimize pressure on an already-formed pressure ulcer. A rubber doughnut-style device should not be used, so the fact that it was not delivered did not contribute to failure to meet the outcome. An increase in serum albumin is a good finding and would increase, not decrease, wound healing. Alcohol interrupts healing, so it is good that nurses did not use alcohol to disinfect the wound.
B)Of the options listed, the only one that would result in poor healing is the right side-back-left side-back turning schedule. This schedule places the client on the back 50% of the time, which is where the ulcer is located. There are six possible body positions when preventing or treating a pressure ulcer, and these positions should be used equally. The nurse should be careful to minimize pressure on an already-formed pressure ulcer. A rubber doughnut-style device should not be used, so the fact that it was not delivered did not contribute to failure to meet the outcome. An increase in serum albumin is a good finding and would increase, not decrease, wound healing. Alcohol interrupts healing, so it is good that nurses did not use alcohol to disinfect the wound.
C)Of the options listed, the only one that would result in poor healing is the right side-back-left side-back turning schedule. This schedule places the client on the back 50% of the time, which is where the ulcer is located. There are six possible body positions when preventing or treating a pressure ulcer, and these positions should be used equally. The nurse should be careful to minimize pressure on an already-formed pressure ulcer. A rubber doughnut-style device should not be used, so the fact that it was not delivered did not contribute to failure to meet the outcome. An increase in serum albumin is a good finding and would increase, not decrease, wound healing. Alcohol interrupts healing, so it is good that nurses did not use alcohol to disinfect the wound.
D)Of the options listed, the only one that would result in poor healing is the right side-back-left side-back turning schedule. This schedule places the client on the back 50% of the time, which is where the ulcer is located. There are six possible body positions when preventing or treating a pressure ulcer, and these positions should be used equally. The nurse should be careful to minimize pressure on an already-formed pressure ulcer. A rubber doughnut-style device should not be used, so the fact that it was not delivered did not contribute to failure to meet the outcome. An increase in serum albumin is a good finding and would increase, not decrease, wound healing. Alcohol interrupts healing, so it is good that nurses did not use alcohol to disinfect the wound.

The Nurse Is Caring for a Client Who Failed to Meet