Active Learning Template: Therapeutic Procedure

Student Name: Procedure Name: Selecting a Dressing for a Stage 2 Pressure Injury Review Module Chapter: 55

Description of Procedure: The procedure involves determining the appropriate dressing for a Stage 2 pressure injury to facilitate healing. A Stage 2 pressure injury is characterized by partial-thickness skin loss involving the epidermis and dermis. The wound may present as a reddish-pink ulcer without slough, eschar, granulation tissue, or adipose tissue. In some cases, it may appear as an intact or ruptured blister.

Indications: This procedure is indicated for patients with a Stage 2 pressure injury to promote healing, prevent infection, and avoid the progression to more severe stages of pressure ulcers.

Outcomes/Evaluation:

• Evaluate the healing process by observing the wound for a decrease in size, depth, redness, and exudate over time.
• If the pressure ulcer does not heal as expected, adjust the treatment plan accordingly.
• Monitor the patient’s pain levels regularly.
• Assess the wound frequently and document any changes in size, depth, color, or exudate.

Considerations:

• Monitor for deterioration to higher-stage ulcerations or infections.
• Be vigilant for signs of systemic infection or sepsis.
• Ensure the patient receives proper nutrition and hydration to support the immune response and wound healing.

Nursing Interventions (Pre, Intra, Post):

• Pre-Procedure:
  • Prevent skin trauma by ensuring the patient is not positioned on any bony prominences.
  • Reposition the patient in bed at least every 2 hours, or every hour if in a chair.
• Intra-Procedure:
  • Inspect the skin frequently and document the patient’s risk using an appropriate tool.
  • Clean the skin thoroughly.
  • Encourage adequate hydration and ensure the patient meets their protein and calorie needs.
  • For a Stage 2 injury, maintain a moist healing environment with a hydrocolloid dressing.
  • Promote natural healing while preventing scar tissue formation.
  • Administer analgesics as needed.
  • Provide nutritional supplements if necessary.
• Post-Procedure:
  • Continue to monitor the pressure ulcer for any changes in appearance or size.

Potential Complications:

• Risk of deterioration to higher-stage ulcerations or the development of infections.
• Possibility of systemic infection or sepsis if not properly managed.

Client Education:

• Educate the patient on the importance of a proper nutritional diet to support healing.
• If the patient is alert and capable, teach them how to change their dressing properly.
• Instruct the patient on the signs of infection and when to seek medical attention.

Nursing Interventions:

• Inspect the wound frequently and report any changes in size, depth, color, or exudate.
• Follow the hospital’s protocol for pressure injury treatment and call a wound care specialist if needed.
• Prevent infection by using aseptic techniques when treating the injury and changing dressings.
• Ensure the patient receives proper nutrition and adequate rest to promote healing.
• Administer antibiotic therapy as needed, following culture and sensitivity testing.