Question

When planning care of the client with a stage-III pressure ulcer, the nurse must be cognizant of the fact that most complications of pressure ulcers relate to which type of event? a. Infection b. Immune reaction c. Fluid imbalance d. Malabsorption

Short answer

a. Infection

Step-by-step solution

Understand the Question

The question asks about the common complications associated with stage-III pressure ulcers. A pressure ulcer, also known as a bedsore, is a localized injury to the skin and underlying tissue usually over a bony prominence. Stage III ulcers have full-thickness skin loss involving damage or necrosis of subcutaneous tissue.

Analyze the Options

Review the provided options for potential complications: a) Infection - infection can occur due to open wounds, b) Immune reaction - indicates a body’s response to foreign substances, c) Fluid imbalance - refers to improper balance of fluids in the body, d) Malabsorption - involves issues with nutrient absorption.

Correlate the Common Complications

Stage-III pressure ulcers are deep wounds that can expose subcutaneous tissues, making them highly susceptible to infection if not properly managed. Infection is a prominent risk because the skin barrier is broken, allowing bacteria to enter the body and cause complications.

Determine the Correct Answer

Compare the information about each option in relation to stage-III pressure ulcers. Infections are the most common and significant complications due to the risk of bacterial invasion of the deep tissue involved in these ulcers.

Key concepts

Nursing Care

Nursing care for patients with stage-III pressure ulcers is intensive and requires diligent attention to detail. Nurses must frequently assess the wound and monitor for signs of infection, following a structured care plan.
Key elements include:

• Regular repositioning to alleviate pressure on the ulcer
• Ensuring proper nutrition and hydration to facilitate healing
• Maintaining a clean and moist wound environment

Effective nursing care is crucial in preventing the ulcer from worsening and promoting recovery.

Pressure Ulcer Management

Managing stage-III pressure ulcers necessitates a multifaceted approach. It involves implementing both preventive and therapeutic measures to promote healing.
Primary strategies include:

• Using pressure-relieving devices like special mattresses and cushions
• Frequent inspections of at-risk areas
• Proper wound care techniques, such as cleaning with appropriate solutions and applying medicated dressings

Pressure ulcer management also entails individualized care plans based on the patient's overall health and needs.

Infection Complications

Infection is a major complication in stage-III pressure ulcers. The ulcer's depth and exposed tissue increase susceptibility to bacterial invasion.
Signs of infection include:

• Redness and swelling around the ulcer
• Pus or foul-smelling drainage
• Increased pain and a rise in body temperature

Prompt recognition and response are critical. Antibiotics and proper wound care are essential to manage and prevent infection spread.

Wound Care Education

Education is a key component in managing stage-III pressure ulcers. Both healthcare professionals and caregivers need comprehensive training.
Important focus areas include:

• Understanding proper wound cleaning and dressing techniques
• Identifying early signs of complications like infection
• Implementing strategies for pressure relief and skin protection

Educating patients and their families ensures continuity of care and empowers them to participate actively in the healing process.