During wound assessment, the nurse suspects a narrow tunnel extending from the wound cavity. Which action provides the most accurate assessment?
Correct answer: A. Gently assess the tract with a sterile applicator and document its direction
- A. Gently assess the tract with a sterile applicator and document its direction
- B. Insert a finger forcefully until resistance is felt
- C. Pack the tract tightly before recording its length
- D. Estimate the tract from the amount of drainage present
Explanation
A sterile applicator can gently identify the direction and extent of tunnelling without forcing tissue apart. The nurse should document the depth and direction, often using the clock-face method. Forceful probing and estimation from drainage can cause injury or produce inaccurate findings.
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About Wound Care and Dressings
Wound care covers wound classification, healing stages, assessment of tissue and drainage, pain, infection signs, dressing selection and clean or sterile dressing technique. It also includes pressure injuries by stage and the factors affecting healing, such as nutrition, circulation, diabetes, infection and prolonged pressure.
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