When admitting a patient with stage III pressure ulcers on both ...

[kellyjaisingh]

When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing?
 
  a. The patient takes insulin daily.
  b. The patient states that the ulcers are very painful.
  c. The patient has had the heel ulcers for the last 6 months.
  d. The patient has several old incisions that have formed keloids.

Question 2

A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure ulcer?
 
  a. Stage I
  b. Stage II
  c. Stage III
  d. Stage IV

[kristenb95]

Answer to Question 1

ANS: A
Chronic insulin use indicates diabetes, which can interfere with wound healing. The persistence of the ulcers over the last 6 months is a concern, but changes in care may be effective in promoting healing. Keloids are not disabling or painful, although the cosmetic effects may be distressing for some patients. Actions to reduce the patient's pain will be implemented, but pain does not directly affect wound healing.

Answer to Question 2

ANS: C
A stage III pressure ulcer has full-thickness skin damage and extends into the subcutaneous tissue. A stage I pressure ulcer has intact skin with some observable damage such as redness or a boggy feel. Stage II pressure ulcers have partial-thickness skin loss. Stage IV pressure ulcers have full-thickness damage with tissue necrosis, extensive damage, or damage to bone, muscle, or supporting tissues.

[kellyjaisingh]

Thank you

[kristenb95]

Happy to help you