A nurse is caring for a client with a stage 2 pressure ulcer on the heel that is in the proliferative phase of wound healing. Which nursing intervention is most appropriate during this phase?
1Apply antimicrobial dressing to prevent infection
2Ensure adequate nutrition to support tissue repair✓ 정답
3Debride necrotic tissue from the wound bed
4Apply cold therapy to reduce inflammation
해설
During the proliferative phase of wound healing, the body is actively building new tissue through collagen synthesis, angiogenesis, and granulation tissue formation. Adequate nutrition, particularly protein and vitamin C, is essential to support these processes and promote optimal healing.
Core Nursing ExplanationKey Concept Analysis: This question tests your understanding of the phases of wound healing and the corresponding stage-specific nursing interventions. The patient has a stage 2 pressure ulcer (partial-thickness skin loss) that is specifically in the proliferative phase. This phase follows the inflammatory phase and is characterized by the growth of new tissue, including granulation tissue, collagen deposition, and angiogenesis (formation of new blood vessels). The primary goal of nursing care during this phase is to Key Point!support and protect the fragile new tissue while providing the body with the essential building blocks it needs.
Answer Rationale: The most appropriate intervention is ② Ensure adequate nutrition to support tissue repair. Key Point! The proliferative phase is metabolically demanding. Protein is crucial for collagen synthesis and cell multiplication, while Vitamin C is a cofactor for collagen formation and capillary integrity. Zinc and adequate overall caloric intake are also vital. Without proper nutrition, wound healing stalls. This intervention directly addresses the core physiological need of this specific phase.
Distractor Analysis:
① Apply antimicrobial dressing to prevent infection: This is a primary intervention during the Watch out for confusion!inflammatory phase or for wounds with signs of infection (increased exudate, odor, erythema). In the proliferative phase of a clean stage 2 ulcer, the focus shifts from infection control to moisture balance and protection. Indiscriminate use of antimicrobials can damage new cells.
③ Debride necrotic tissue from the wound bed: Debridement is the removal of non-viable tissue (slough, eschar). This is a critical intervention to prepare the wound bed, but it is performed Watch out for confusion!before the proliferative phase can begin. A wound in the true proliferative phase should have a clean, red, granular bed. Debriding a proliferating wound would harm the new tissue.
④ Apply cold therapy to reduce inflammation: Cold therapy (vasoconstriction) is indicated in the Watch out for confusion!acute inflammatory phase (first 24-48 hours) to minimize swelling and pain. In the proliferative phase, warmth (vasodilation) is beneficial as it increases blood flow and oxygen delivery to support tissue growth.
Related Concepts: Understanding wound bed preparation (TIME framework: Tissue, Infection/Inflammation, Moisture, Edge) is crucial. For a stage 2 pressure ulcer in proliferation, maintaining a moist wound environment with a simple hydrocolloid or foam dressing is often ideal to protect the granulation tissue and facilitate epithelialization.
Concept Summary
Phase of Healing
Timeline
Key Processes
Primary Nursing Focus
Inflammatory
Day 1-4
Hemostasis, phagocytosis
Control bleeding, prevent infection, manage edema/pain
Provides amino acids, vitamins, minerals for tissue synthesis
Always important, but the demand peaks during proliferation.
Anatomy, Physiology & Pharmacology Points
Physiology: The proliferative phase relies on fibroblasts producing collagen Type III, which is later remodeled into stronger Type I. Angiogenesis creates a capillary network within the granulation tissue, giving it a beefy red appearance.
Nutrition: Key nutrients include Protein (for collagen and new cells), Vitamin C (hydroxylation of proline for collagen), Zinc (cofactor for enzymes), and Vitamin A (supports epithelialization and immune function).
Memory Tips
Phases in Order: "I P M" - Inflammatory, Proliferative, Maturation. For Proliferative, think "P for Protein and Production of new tissue."
Stage 2 Ulcer: Remember it's partial-thickness. Visualize a blister, abrasion, or shallow crater. The dermis is exposed (red/pink), but fat and muscle are not visible.
High-Frequency NCLEX Topics
NCLEX loves to test the timing and rationale behind nursing actions. You will see questions that ask for the "priority" intervention for a wound in a specific phase, or questions that require you to identify the phase based on a wound description (e.g., "beefy red tissue" = proliferative).
Watch Out for Question Variations!
Shift from Phase to Symptom: "A client's wound has bright red, granular tissue. The nurse identifies the wound is in which phase of healing?" (Answer: Proliferative).
Shift from Intervention to Assessment: "When assessing a client's wound in the proliferative phase, which finding does the nurse expect?" (Answer: Clean wound bed with red granulation tissue).
Shift to Prioritization: "The nurse is caring for a client with a pressure ulcer. Which client finding requires immediate intervention?" If the wound has necrotic tissue, the answer would shift to debridement, as that must happen before proliferation can occur.
Nursing Clinical Practice GuideClinical Scenario: You are assigned to Mr. Johnson, a 78-year-old with limited mobility due to a stroke. He has a 3cm x 2cm stage 2 pressure ulcer on his right heel. The wound bed is moist, beefy red, with no signs of infection (no pus, foul odor). The wound is clearly in the proliferative phase.
Nursing Intervention Strategy:
Assessment: Perform a comprehensive nutritional assessment. Check albumin/prealbumin levels (Albumin < 3.5 g/dL indicates risk), recent weight loss, and dietary intake. Assess the wound at each dressing change for progression (increasing granulation, decreasing size).
Planning & Implementation:
Nutrition: Collaborate with the dietitian. Ensure intake of high-protein foods (eggs, poultry, fish, supplements). Encourage fruits/vegetables high in Vitamin C (citrus, bell peppers). Provide oral nutritional supplements if intake is poor.
Wound Care: Cleanse with normal saline. Apply a moisture-retentive dressing like a hydrocolloid or foam to protect the fragile granulation tissue, maintain a moist environment, and absorb minimal exudate. Change dressing per protocol or when soiled.
Pressure Relief: This is continuous! Use heel protectors or pillow off-loading. Reposition the patient at least every 2 hours.
Evaluation: Monitor for signs of healing (wound contraction, epithelialization from edges) weekly. Re-assess nutritional markers. If healing stalls, re-evaluate for infection, nutritional deficits, or inadequate off-loading.
Patient Safety and Precautions:
Never use adhesive dressings that are too tight on fragile skin.
Avoid cytotoxic cleansers (e.g., hydrogen peroxide, povidone-iodine) on granulation tissue; they kill new cells.
Monitor for allergic reactions to dressings.
Nursing Procedure & Medication FlowDressing Change for Proliferating Stage 2 Ulcer:
1. Perform hand hygiene, don gloves.
2. Gently remove old dressing. If it adheres, moisten with saline to avoid stripping new tissue.
3. Cleanse wound with gentle irrigation using normal saline.
4. Pat surrounding skin dry; keep wound bed moist.
5. Apply appropriate moisture-retentive dressing (e.g., hydrocolloid).
6. Secure dressing without tension.
7. Document wound characteristics (color, size, exudate) and patient tolerance.
Nutritional Support Flow:
- If oral intake is < 50% of meals for 3 days, notify the provider/dietitian.
- Consider high-protein, high-calorie oral supplements between meals.
- For severe deficits, enteral (tube) feeding may be initiated.
A Word from Your Senior Nurse
"Remember, the wound you see on the outside is a window into what's happening inside the patient's body. A wound that isn't healing in the proliferative phase is often shouting, 'I need more protein! I need more vitamins!' Your role is to be that detective and advocate. On the NCLEX and in practice, always link your wound care interventions back to the phase of healing. It's not just a 'dressing choice'—it's a physiological strategy. Think phase, think purpose, and you'll choose the right action every time."
Proliferative Phase — The second phase of wound healing, characterized by granulation tissue formation, collagen synthesis, and angiogenesis.
Granulation Tissue — New, fragile connective tissue and microscopic blood vessels that form during the proliferative phase, appearing red and bumpy.
Stage 2 Pressure Ulcer — Partial-thickness skin loss involving epidermis and/or dermis. Presents as a shallow open ulcer, blister, or abrasion.
Debridement — The removal of non-viable tissue (necrotic, slough, eschar) from a wound to promote healing.
Moist Wound Healing — A principle of maintaining a moist wound environment under a dressing to facilitate cell migration and epithelialization, preventing scab formation.