When a nurse sees eschar on a client's heel, what nursing goal should be implemented?

When a nurse sees eschar on a client's heel, what nursing goal should be implemented?

• A. Debride the wound
• B. Cleanse and protect the area
• C. Promote epithelialization
• D. Promote remodeling

Answer: (A)

When eschar is present on a client's heel, the primary nursing goal should focus on debridement of the wound. Eschar is a dry, necrotic tissue that covers a wound, and it can impede the healing process by providing a barrier to the formation of new tissue. Debridement, which involves the removal of necrotic tissue, is essential to create a healthy environment for healing and to reduce the risk of infection. By removing the eschar, the wound can be more effectively assessed and treated, allowing for better adherence of dressings or topical treatments. This step is crucial in wound management, especially in cases where eschar is present, as it facilitates the transition to the next phases of healing. In contrast, while cleansing and protecting the area is important for all wound types, and promoting epithelialization and remodeling are later stages of healing, the presence of eschar specifically indicates that debridement is necessary to advance the healing process effectively.

When eschar is present on a client's heel, the primary nursing goal should focus on debridement of the wound. Eschar is a dry, necrotic tissue that covers a wound, and it can impede the healing process by providing a barrier to the formation of new tissue. Debridement, which involves the removal of necrotic tissue, is essential to create a healthy environment for healing and to reduce the risk of infection.

By removing the eschar, the wound can be more effectively assessed and treated, allowing for better adherence of dressings or topical treatments. This step is crucial in wound management, especially in cases where eschar is present, as it facilitates the transition to the next phases of healing.

In contrast, while cleansing and protecting the area is important for all wound types, and promoting epithelialization and remodeling are later stages of healing, the presence of eschar specifically indicates that debridement is necessary to advance the healing process effectively.