Before irrigating a stage III pressure ulcer on the heel, what is the first action the nurse should take?

Before proceeding with the irrigation of a stage III pressure ulcer on the heel, assessing the client’s pain level is crucial. This action is essential because managing a patient's comfort and pain is a fundamental aspect of nursing care. A pressure ulcer, particularly one that is deep and extensive as a stage III would be, can lead to significant discomfort during the irrigation process. By checking the client’s pain level first, the nurse can determine whether additional interventions are necessary, such as administering pain medication or ensuring the client is in a more comfortable position.

Addressing pain before wound care not only helps in providing a more humane and patient-centered approach but also ensures that the client is more relaxed, which can facilitate the irrigation process itself. Once the client’s pain level is assessed, appropriate actions can be taken to ensure their comfort before moving on to the procedure, thereby promoting a better overall experience and potentially improving healing outcomes.

Gathering supplies and applying a sterile dressing are also important steps, but they would logically follow after ensuring that the client is comfortable and any pain is managed. Cleaning the wound with saline might be part of the irrigation process, but it should not commence until the client’s pain has been assessed and addressed if necessary.