A nurse is caring for a 45-year-old patient with spinal cord injury who has developed a stage 2 pressure ulcer on the sacrum. Which nursing intervention is most appropriate for promoting wound healing?
1Apply a dry gauze dressing and change it every 8 hours
2Clean the wound with hydrogen peroxide and apply antibiotic ointment
3Maintain a moist wound environment using hydrocolloid dressing✓ 정답
4Massage the surrounding skin to improve circulation
해설
Maintaining a moist wound environment with hydrocolloid dressing is most appropriate for stage 2 pressure ulcers to promote optimal healing. Dry dressings, hydrogen peroxide, and massage can delay healing or cause further damage.
Core Nursing ExplanationKey Concept Analysis: This question tests the application of Evidence-Based Wound Care principles for a Stage 2 pressure ulcer. The core concept is understanding that modern wound management prioritizes a Key Point!moist wound environment to facilitate epithelial cell migration and autolytic debridement, which accelerates healing. A stage 2 ulcer involves partial-thickness skin loss (epidermis and possibly dermis), presenting as a shallow open ulcer or intact/ruptured blister. The patient's spinal cord injury is a critical risk factor due to immobility and sensory loss, making meticulous skin care and appropriate dressing selection paramount.
Answer Rationale: Key Point! Hydrocolloid dressings are a standard of care for stage 2 pressure ulcers. They create an optimal moist healing environment by absorbing light exudate while maintaining hydration at the wound bed. They are also occlusive, protecting the wound from contamination and friction, and can remain in place for several days, reducing disruption to the fragile healing tissue. This aligns perfectly with the goal of promoting wound healing.
Distractor Analysis: Watch out for confusion! Option ① (Dry gauze) is incorrect because it creates a dry environment. As the gauze dries, it can adhere to the wound bed, causing trauma and pain during dressing changes, and it desiccates the wound, which impairs epithelial cell migration.
Option ② (Hydrogen peroxide & antibiotic ointment) is incorrect and potentially harmful. Hydrogen peroxide is cytotoxic and can damage healthy granulation tissue, delaying healing. Topical antibiotic ointments are not indicated for clean pressure ulcers and can promote antibiotic resistance or contact dermatitis. Normal saline is the preferred cleansing solution for most wounds.
Option ④ (Massage surrounding skin) is a dangerous practice for patients at risk for or with existing pressure ulcers. Key Point! Massaging bony prominences or areas with compromised skin can cause shear and friction, damaging underlying tissue and potentially worsening the ulcer. Instead, skin should be inspected and kept clean and dry.
Related Concepts: This question integrates knowledge of pressure ulcer staging (NPUAP classification), principles of moist wound healing, selection of appropriate wound dressings based on wound characteristics (e.g., hydrocolloid for light exudate, foam for moderate-heavy exudate), and the specific vulnerabilities of patients with spinal cord injury (SCI). It also touches on nursing interventions to prevent further skin breakdown, such as regular repositioning and use of pressure-redistributing surfaces.
Concept Summary
Concept
Key Takeaway
Pressure Ulcer Staging (NPUAP)
Stage 2: Partial-thickness loss. Shallow open ulcer or blister. Red/pink wound bed, no slough.
Ideal for Stage 1/2 ulcers, light exudate. Creates moist environment, occlusive, protects from shear/friction.
Wound Cleansing
Use normal saline or wound cleanser. Avoid cytotoxic agents (hydrogen peroxide, povidone-iodine) on granulating tissue.
SCI & Skin Care
High risk due to immobility, sensory loss, moisture. Prevent with Q2hr turns, specialty surfaces, meticulous skin inspection.
Side-by-Side Comparison!
Intervention
Appropriate Use
Inappropriate Use / Harm
Hydrocolloid Dressing
Stage 1/2 pressure ulcers, wounds with light exudate, to maintain moist environment.
Wounds with heavy exudate or infection (can trap bacteria).
Dry Gauze Dressing
Temporarily covering a bleeding wound, as a secondary dressing over a primary moist dressing.
On a clean, granulating pressure ulcer (causes desiccation and trauma).
Skin Massage
On healthy, muscular areas to promote relaxation (e.g., back massage).
Over any bony prominence or area of erythema (increases risk of shear injury).
Anatomy, Physiology & Pharmacology Points
Pathophysiology: Pressure ulcers form due to unrelieved pressure, shear, and friction, leading to ischemia and necrosis of skin and underlying tissue. The sacrum is a high-risk bony prominence.
Healing Physiology: A moist environment supports the inflammatory and proliferative phases of healing. It keeps growth factors and cells in contact with the wound bed and allows for easier migration of epithelial cells across the surface.
Dressing Pharmacology: Hydrocolloid dressings contain gel-forming agents (like carboxymethylcellulose) that interact with wound exudate to form a moist gel over the wound.
Memory Tips
M.O.I.S.T. is best for healing: Moist environment, Occlusive/protective, Ideal for Stage 2, Saline for cleaning, Turn patient Q2H.
Say NO to H2O2: Remember, Hydrogen Peroxide is for disinfecting surfaces, not healing wounds on people.
Massage Myth: Think "M" for Massage causes "M"ore damage on bony "M"ounds (prominences).
High-Frequency NCLEX Topics
Pressure ulcer prevention and management is a Core and High Yield topic. The NCLEX-RN frequently tests on: 1) Identifying correct ulcer stage from a description/image, 2) Selecting appropriate nursing interventions/wound dressings for each stage, 3) Prioritizing preventive measures (e.g., turning schedules, specialty beds), and 4) Recognizing inappropriate/harmful actions (like using donut rings or massaging reddened areas).
Watch Out for Question Variations!
The same concept can be tested in many ways:
Priority Action: "The nurse notes a stage 2 pressure ulcer. What should the nurse do first?" (Answer: Assess the wound thoroughly and document characteristics).
Patient Education: "Which statement by a family member indicates understanding of pressure ulcer care?" (Correct: "I will make sure she is turned every two hours." Incorrect: "I will rub lotion on the red spot on her tailbone.").
Evaluation: "Which finding indicates the hydrocolloid dressing is effective?" (Answer: Wound bed appears pink/moist, edges are attached, no signs of infection).
Nursing Clinical Practice GuideClinical Scenario: You are assigned to Mr. Johnson, a 45-year-old with a T6 complete spinal cord injury (SCI) from a motorcycle accident 3 months ago. During your morning assessment, you find a 3cm x 2cm shallow, moist, red wound on his sacrum with no slough or eschar. The surrounding skin is intact but slightly red. He reports no pain at the site.
Nursing Intervention Strategy:
Assessment: Perform a comprehensive wound assessment using the TIME framework: Tissue (viable, non-viable), Infection/Inflammation, Moisture balance, Edge of wound. Document size, depth, color, exudate, odor, and peri-wound skin. Stage it correctly (Stage 2). Assess his nutritional status (protein, vitamin C, zinc are crucial for healing) and his current pressure redistribution surface.
Planning & Implementation: The primary goal is to promote healing and prevent progression. Collaborate with the wound care nurse. Cleanse the wound gently with normal saline. Apply a hydrocolloid dressing sized 2 inches larger than the wound. Reinforce the turning schedule—use a clock to turn him at least every 2 hours. Ensure he is on an appropriate pressure-redistributing mattress (e.g., low-air-loss mattress). Optimize nutrition; consult a dietitian if intake is poor.
Patient & Family Education: Teach Mr. Johnson and his family about the cause of the ulcer. Emphasize that he cannot feel pressure, so visual inspection (with a mirror) is essential. Teach them to check for redness during care. Explain the purpose of the dressing (to keep it moist and protected) and when to notify the nurse (if dressing leaks, wound smells, or fever develops).
Evaluation: Evaluate dressing integrity during each turn. Upon scheduled dressing changes (every 3-5 days or if soiled), evaluate for signs of healing: decreasing wound size, formation of pink granulation tissue, and clean edges. Also monitor for signs of infection (increased exudate, purulence, odor, fever, worsening redness).
Patient Safety and Precautions:
Never use donut-shaped cushions or rings. They increase pressure on surrounding tissue and impair circulation to the area at risk.
Avoid vigorous rubbing during bathing or drying. Pat the skin dry gently.
Monitor for moisture from incontinence. Use moisture-barrier creams and breathable, absorbent incontinence products. Skin must be kept clean and dry.
Nursing Procedure & Medication FlowProcedure: Applying a Hydrocolloid Dressing
Medication Note: Topical treatments like antibiotic ointments or enzymatic debriders are not first-line for a clean Stage 2 ulcer. Their use requires a specific order and indication (e.g., signs of infection, necrotic tissue).
A Word from Your Senior Nurse
"Remember, a pressure ulcer is often a sign of a systemic nursing care problem, not just a local skin issue. It tells us about the patient's mobility, nutrition, hydration, and the effectiveness of our preventive care. When you see one, it's a call to action to re-evaluate the entire care plan. On the NCLEX, they love to test if you know the difference between outdated practices (like dry gauze and peroxide) and current evidence. In real life, being the nurse who champions evidence-based wound care can literally save your patient's skin—and prevent a lot of suffering. Connect the dots between the pathophysiology (pressure causes ischemia) and the intervention (relieve pressure, support healing). That's the kind of critical thinking that makes a great nurse!"