Which action may the nurse institute independently (when caring for a client with a 3-cm stage I pressure ulcer on the coccyx)?
A. Using a povidone-iodine wash on the ulceration three times per day B. Using normal saline solution to clean the ulcer and applying a protective dressing as necessary C. Applying an antibiotic cream to the area three times per day D. Massaging the area with an astringent every 2 hours
Pressure ulcers can be very painful. Often people get pressure ulcers from too much pressure on one part of the body. The ulcers can take place due to bed sores. There are actually different stages of pressure ulcers. The stages start with the mildest and go to the most extreme.
The first stage is the mildest and the pressure ulcer is at the top part of the skin. The second stage is further below the skin. The ulcer may look red.
The third stage occurs when the ulcer looks like a hole in the skin and it may smell bad. The fourth stage has the worst ulcers. If a nurse is caring for a client with a pressure ulcer, he or she will need to use a normal saline solution to clean the ulcer.
Using normal saline solution to clean the ulcer and applying a protective dressing as necessary-rationale: the nurse may wash the area with normal saline solution and apply a protective dressing. these interventions will protect the area and are within the nurses scope of practice. a nurse must obtain a physicians order to use a povidone-iodine wash or an antibiotic cream. massaging with an astringent can further damage the skin.client needs category: physiological integrityclient needs subcategory: basic care and comfortcognitive level: applicationreference: taylor, c., et al. fundamentals of nursing: the art and science of nursing care, 6th ed. philadelphia: lippincott williams & wilkins, 2008, p. 315.