The nurses employed at a wound therapy clinic are preparing an ...

[bobypop]

The nurses employed at a wound therapy clinic are preparing an educational in-service about the vacuum-assisted closure (VAC) device for hospital nurses. What accurate information will be included in this in-service? (Select all that apply.)
 
  a. Positive pressure is applied by this device
  b. Healing is facilitated by decrease in drainage
  c. Promotes formulation of granulation tissue
  d. Reduces local and peripheral edema
  e. Drops bacterial level in wound

Question 2

A patient with a diagnosis of insulin dependent diabetes mellitus is being treated for a stage II foot ulcer. The patient refuses to follow an ADA diet as ordered by a physician and is morbidly obese.
 
  The nurse assesses the ulcer to be healing, free from signs and symptoms of infection, with a positive pedal pulse and warm to touch. What nursing diagnosis will be identified as a priority?
  a.
  Infection
  b.
  Altered nutrition: more than body requirements
  c.
  Impaired skin integrity
  d.
  Altered peripheral tissue perfusion

[aidanmbrowne]

Answer to Question 1

ANS: C, D, E
Vacuum-assisted closure (VAC) devices apply negative pressure and increase drainage. Healing is facilitated by promotion of granulation tissue, decreased local and peripheral edema, and in 3 to 4 days following application a drop in bacterial level in the wound should be observed.

Answer to Question 2

ANS: B
The nurse's assessment identifies no signs of infection, that the wound is healing with positive pedal pulse and skin warm to touch ruling out infection, impaired skin integrity, and altered peripheral tissue perfusion as priorities at this time. The priority nursing diagnosis for this patient is Altered Nutrition: more than body requirements related to diet noncompliance.