# A nurse is caring for a client with a stage 3 pressure ulcer on the sacrum that is in the proliferative phase of wound healing. Which nursing intervention is most appropriate to promote optimal healing during this phase?

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## 문제

A nurse is caring for a client with a stage 3 pressure ulcer on the sacrum that is in the proliferative phase of wound healing. Which nursing intervention is most appropriate to promote optimal healing during this phase?

## 보기

1. Apply a hydrocolloid dressing to maintain a moist wound environment and protect new tissue growth **✔ 정답**
2. Perform aggressive wound debridement to remove all granulation tissue
3. Apply a dry gauze dressing and change it every 2 hours to keep the wound dry
4. Use hydrogen peroxide to cleanse the wound and eliminate all bacteria

**정답: 1**

## 해설

During the proliferative phase of wound healing, the priority is to maintain a moist wound environment that supports granulation tissue formation and epithelialization. Hydrocolloid dressings provide optimal conditions for healing by maintaining moisture while protecting the delicate new tissue.

The proliferative phase of wound healing is a critical healing stage occurring 3-21 days after injury, characterized by granulation tissue formation, collagen synthesis, and epithelialization. This phase requires special care for optimal healing outcomes.

Granulation tissue appears as red, bumpy tissue filling the wound bed and provides the foundation for new tissue growth. This tissue is highly vascular and fragile, requiring protection from trauma and desiccation. The proliferative phase includes several key processes: angiogenesis (new blood vessel formation), fibroblast proliferation (fibrous tissue formation), and epithelialization (migration of epithelial cells across the wound surface).

Hydrocolloid dressings are ideal for wounds in the proliferative phase because they maintain a moist wound environment, providing conditions essential for cell migration, enzyme function, and tissue repair. These dressings interact with wound exudate to form a gel, creating an optimal healing environment while protecting the wound from external contaminants. The moist environment promotes faster epithelialization and reduces pain.

Proper interventions support the natural healing process by providing optimal conditions for tissue repair. Moisture maintenance is crucial as it facilitates the migration of growth factors, nutrients, and immune cells necessary for healing. Additionally, the moist environment prevents eschar (dry scab) formation, which can impede healing and increase scarring.

This knowledge is essential for NCLEX-RN success as wound care is a core nursing competency. Understanding wound healing phases and appropriate interventions for each stage demonstrates critical thinking skills essential for safe nursing practice.

## 심화 해설

Understanding the Proliferative Phase

To select the most appropriate intervention, it is essential to understand what is happening in the wound during the proliferative phase of healing. This phase is characterized by the formation of new tissue to fill the wound defect. Key processes include angiogenesis (formation of new blood vessels), the synthesis of collagen by fibroblasts, and the development of granulation tissue. This new tissue is highly vascular, fragile, and requires a protected environment to thrive. The primary goal of nursing care during this phase is to support these natural rebuilding processes while preventing disruption or damage to the new cells.

Analysis of Interventions

Let's examine why a hydrocolloid dressing is the correct choice and why the other options are harmful, particularly for a stage 3 pressure ulcer in this healing phase.

- **Correct Answer: Apply a hydrocolloid dressing.**

This intervention aligns perfectly with the principle of moist wound healing. A hydrocolloid dressing is an occlusive or semi-occlusive dressing that maintains a moist wound environment by trapping wound exudate. The provided evidence confirms that "moist wound healing, an established paradigm in the management of wounds, accelerates healing by maintaining an optimal microenvironment" [3]. This moist environment is critical during the proliferative phase because it facilitates cell migration, promotes granulation and epithelialization, and protects the delicate new tissue from desiccation and trauma [3]. The dressing also provides a protective barrier over the stage 3 ulcer, which involves full-thickness skin loss, shielding the newly formed tissue from external contaminants.

- **Why Other Options Are Incorrect:**

- **Option 2: Perform aggressive wound debridement.**

Debridement is the removal of necrotic, non-viable tissue. Its primary role is in the inflammatory phase to reduce bacterial load and remove a physical barrier to healing. In the proliferative phase, the wound bed should be clean and filled with healthy red granulation tissue. Aggressively debriding this tissue would destroy the new blood vessels and collagen matrix the body is working to build, reversing the healing progress. This action is contraindicated.

- **Option 3: Apply a dry gauze dressing.**

A dry gauze dressing is non-selective and can cause significant trauma. As it dries, it adheres to the wound bed. Upon removal, it mechanically strips away new granulation tissue, epithelial cells, and disrupts the healing process. Furthermore, a dry environment leads to cell desiccation and death, directly contradicting the moist wound healing principle essential for this phase [3].

- **Option 4: Use hydrogen peroxide to cleanse the wound.**

Hydrogen peroxide is a cytotoxic agent. While it can kill bacteria, it is non-selective and also destroys healthy cells, including fibroblasts and new capillary buds that are vital for the proliferative phase. Using it on a healing stage 3 ulcer would cause chemical damage to the wound bed, significantly delaying healing. Normal saline is the standard, safe cleansing solution for wounds with granulation tissue.

Clinical Reasoning and Pathophysiology

The transition from the inflammatory to the proliferative phase is a critical juncture in wound repair. Research highlights the importance of accurately recognizing and regulating the transition of macrophages from a pro-inflammatory (M1-like) to an anti-inflammatory (M2-like) state to improve chronic inflammation in pressure injuries . A persistent inflammatory state, often seen in chronic wounds, prevents progression into the proliferative phase. For a stage 3 pressure ulcer that has successfully entered the proliferative phase, the clinical priority shifts from managing inflammation and removing debris to actively supporting and protecting new tissue growth. The selection of a dressing that maintains a moist, insulated, and protected microenvironment is the most direct and evidence-based nursing action to promote optimal healing during this specific phase of tissue repair [3].

References (research sources)

- [3]Role of a topical hydrogel (Dermatix<sup>®</sup> wound care gel) in acute and chronic wound management: a case series of real-world experiences and expert opinion from Asia.Case reportLee CY, Chang EWH, Chew KY, Karupayah V, Latief W, Le VA, Tobing D, Vu TPT, Wong KC. (2026) · DOI: 10.7573/dic.2025-8-3

## 임상 시나리오

Proliferative Phase Wound ManagementProtecting Granulation Tissue with Moist Dressings
During the proliferative phase, the wound bed fills with new, fragile granulation tissue. The primary goal is to protect this tissue and maintain a moist wound environment to support cell migration and collagen synthesis.

Apply a hydrocolloid dressing to manage light to moderate exudate. This forms a protective gel, keeps nerve endings moist to reduce pain, and provides a barrier against contaminants without adhering to the wound bed.

CautionNever use cytotoxic cleansers like hydrogen peroxide or perform aggressive debridement on granulation tissue. These actions destroy healthy fibroblasts and new capillaries, reversing the healing process.

## 핵심 개념

- **Proliferative Phase** — The second phase of wound healing characterized by angiogenesis, collagen synthesis, and granulation tissue formation to fill the wound bed.
- **Hydrocolloid Dressing** — An occlusive or semi-occlusive dressing that absorbs exudate to form a gel, maintaining a moist wound environment optimal for cell migration and tissue growth.
- **Granulation Tissue** — Newly formed, highly vascular, fragile connective tissue composed of new capillaries and fibroblasts, appearing pink or red in a healing wound.
- **Moist Wound Healing** — An evidence-based principle where maintaining a balanced moist environment accelerates re-epithelialization and collagen synthesis compared to dry healing.
- **Stage 3 Pressure Ulcer** — Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.

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