Author Question: A patient on the unit has a deep decubitus ulcer. The family asks why the nurse debrides the ulcer ... (Read 103 times)

altibaby · **on:** Jul 23, 2018

A patient on the unit has a deep decubitus ulcer. The family asks why the nurse debrides the ulcer and removes the dead cells. What is the nurse's best response to explain to the family why debridement is performed?

A) The lysosomes released by the dead cells in the area continue to kill other cells, destroying more tissue.
B) The dead cells no longer contain histocompatible antigens causing a greater inflammatory response.
C) Removing dead tissue forces oxygen to enter the damaged cells to regenerate them and to promote healing.
D) The doctor ordered the procedure to be performed so it is done the way it is ordered because orders are always followed.

Question 2

According to the Gate Control Theory, what interventions by the nurse could help to block pain impulses?

A) Administration of opioid medications
B) Administration of narcotic agonist-antagonists
C) Back massage
D) Acupuncture

enass · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

A
Feedback:
When a cell dies, its cell membrane ruptures and the lysosomes release lysozymes, which dissolve protein. When many cells die, lysozymes accumulate and dissolve the proteins that the dead cells leave behind, but the lysozymes also destroy the cell membrane of healthy cells in the area. Those cells then die, releasing lysozymes, which destroy more cells, and a vicious cycle occurs. A decubitus ulcer is an area of many dead cells, which are killing healthy cells. The area needs to be scraped clean to remove the dead cells so that the lysozymes will stop destroying healthy cells and allow oxygen to return to the area through the capillary bed, which allows healing to occur. Many treatments exist for decubitus ulcers, all of which depend on the return of blood flow to the area and removal of the dead tissue. No procedure should ever be performed only because it was ordered. The nurse should understand why each procedure is needed.

Answer to Question 2

C
Feedback:
According to the gate control theory, the transmission of these impulses can be modulated or adjusted all along these tracts. All along the spinal cord, interneurons can act as gates by blocking the ascending transmission of pain impulses. It is thought that the gates can be closed by stimulation of the larger A fibers and by descending impulses coming down the spinal cord from higher levels in such areas as the cerebral cortex, the limbic system, and the reticular activating system. Administration of medications does not use the Gate Control Theory. Acupuncture uses the Gate Control Theory but is not performed by the nurse.