A patient with diabetes has a new foot ulcer. Which nursing action is most appropriate during the initial assessment?
Correct answer: A. Inspect and measure the ulcer, then assess circulation and sensation
- A. Inspect and measure the ulcer, then assess circulation and sensation
- B. Apply a dressing before examining the surrounding skin
- C. Ask the patient to walk to determine the wound's severity
- D. Clean the ulcer forcefully until all tissue appears red
Explanation
The initial assessment should document wound features and evaluate circulation and sensation because diabetes increases the risk of impaired healing and neuropathy. Dressing or cleansing should follow assessment and appropriate wound-care principles.
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About Nursing Process and Health Assessment
Assessment gathers subjective and objective data through health history, physical examination and observation. The nursing process then uses nursing diagnoses, planning, implementation and evaluation to provide individualised care, while distinguishing a nursing diagnosis from a medical diagnosis and identifying priorities such as airway, breathing, circulation and safety.
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