A nurse is evaluating a stage II pressure ulcer on a client. Which assessment findings should prompt the nurse to request a referral from the wound care specialist?
Understand the Problem
The question is asking which characteristics of a stage II pressure ulcer would necessitate a referral to a wound care specialist. It's a multiple-choice question where you need to understand wound assessment and when specialized care is needed.
Answer
A wound with tan, leathery tissue should be referred to a wound care specialist.
The assessment finding that should prompt the nurse to request a referral from the wound care specialist is a wound measuring 2 cm x 2 cm x 0.5 cm with tan leathery appearance.
Answer for screen readers
The assessment finding that should prompt the nurse to request a referral from the wound care specialist is a wound measuring 2 cm x 2 cm x 0.5 cm with tan leathery appearance.
More Information
The presence of tan, leathery tissue in a wound, regardless of size, indicates a need for evaluation by a wound care specialist. This is because tan, leathery tissue may indicate the presence of necrotic tissue, which can impede wound healing and increase the risk of infection.
Tips
When assessing wounds, it is important to look at the color of the tissue in the wound bed. Red tissue is usually healthy and indicates that the wound is healing. Pale or gray tissue may indicate poor blood flow, and black tissue is usually dead and needs to be removed.
Sources
- MS Ch. 10 flashcards - quizlet.com
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