The nurse observes a thick,tannish-brown covering over a large wound and needs to stage the wound.What action by the nurse is most appropriate?

Question

Quizplus · Accepted Answer

The tannish-brown covering is eschar,which has formed as a result of the severe tissue injury.Until the base of the wound can be seen,the true depth and therefore the stage cannot be determined.Eschar is not simply removed; often it is scored,and a solution is put on it to soften it so it can be removed.When the eschar is removed,sterile instruments are used because removing it exposes fresh tissue.If the nurse applies the dressing over eschar,the dressing effectively seals the necrotic tissue onto the wound bed.Silicone lotion is contraindicated for use in a large crater.A hydrocolloid dressing creates its own seal and cannot be used until the eschar has been removed.

The Nurse Observes a Thick,tannish-Brown Covering Over a Large Wound