The nurse is caring for a client with a chronic wound. Which of the following are wound treatments that may assist with the healing process?

A. Inform the client that the recovery nurse will instruct them how to manage postoperative pain:

This is an important aspect of postoperative care, but it is typically addressed by the post-anesthesia care unit (PACU) or recovery nurse after surgery rather than in the preoperative education phase. While pain management education is crucial, the focus of preoperative education is usually on what to expect before, during, and immediately after surgery.

B. Remind the client they will return to their room after surgery:

This information is part of the preoperative instructions and helps alleviate anxiety by providing clarity about the post-surgical process. However, it may not be the most critical aspect of preoperative education compared to other options.

C. Provide instructions about how to cough and deep breathe effectively:

This is a key nursing intervention to include in preoperative education. Teaching the client how to cough and deep breathe effectively helps prevent postoperative complications such as atelectasis and pneumonia. These breathing techniques are typically taught preoperatively to ensure the client understands and can perform them correctly after surgery.

D. Notify the client that they will receive a food tray in the recovery room:

While it's important for the client to understand the postoperative diet plan, including any dietary restrictions or instructions, this information is usually provided after surgery rather than in the preoperative education phase.

A. Stage III pressure injury

Stage III pressure injuries involve full-thickness skin loss, extending into the subcutaneous tissue but not through the fascia. These wounds typically present as deep craters and may involve undermining or tunneling. Non-blanchable erythema alone without visible skin loss is not characteristic of a Stage III pressure injury.

B. Stage IV pressure injury

Stage IV pressure injuries are the most severe and involve full-thickness tissue loss with exposed bone, tendon, or muscle. These wounds often have extensive tissue damage and can be difficult to manage. Again, non-blanchable erythema without visible skin loss is not indicative of a Stage IV pressure injury.

C. Stage II pressure injury

Stage II pressure injuries involve partial-thickness skin loss with damage to the epidermis and possibly the dermis. These wounds often present as shallow open ulcers or blisters and may have characteristics such as intact or ruptured blisters. While Stage II injuries can present with erythema, non-blanchable erythema specifically indicates a Stage I injury.

D. Stage I pressure injury

Stage I pressure injuries are the earliest stage and involve non-blanchable erythema of intact skin. The skin may be warmer or cooler than surrounding tissue and may have changes in sensation. There is no visible skin loss at this stage, but the area is at risk for further injury if pressure is not relieved. Therefore, non-blanchable erythema on the heels most likely indicates a Stage I pressure injury.