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Moisture (Incontinence, diaphoresis)
Reduces skin's resistance to other forces such as pressure or shear
Guidlines for Prevention & Mgmt of Pressure Ulcers
Predictive tool for pressure ulcer development; identification of patients at risk
Pressure Ulcer Etiology
Ischemia with tissue hypoxia (develops within 2 hrs).
Unreleived pressure or mechanical trauma.
Over a period of time
Significance of the Braden Scale
Older Adult Patient with a score of 18 or below: at risk
Should be used when client first enters the facility, again Q 24 hrs & whenever his condition changes
Redness that persists after palpation, indicating tissue damage (Stage I P.U>)
Partial-thickness loss of skin
Shallow, open ulcer
Intact or open/ruptured serum-filled blister
Full-thickness loss of skin
Subcutaneous fat may be visible
Undermining & tunneling may be present
Full-thickness loss of skin with exposure of bone, tissue or muscle
Undermining & tunneling are common
Emergency Setting Wound Assessment
Abrasion, laceration, puncture, wound contamination, need for tetanus
Wound healing process where skin edges close, little to no tissue loss, no infection (approximated, surture, staples)
Wound healing process where healing occurs gradually, skin edges do not close (wound left open), granulation occurs
Wound healing process where wound repair is needed because of loss of epidermis and dermis
Phase 3 Proliferation
Primary intention wound develops new tissue (period of granulation) and collagen. The wound contracts with epithelialization.
Secondary intention wound fills in with granulation tissue, followed by contractionand epithelialization.
Collagen is formed into a scar, to increase the strength of the wound. Yet still only 80% as strong as the original tissue. Scar should become thinner & paler over time.
Complications of wound healing
Hemorrhage, infection, dehiscence (seperation), evisceration (extrusion), fistula
When are s/s of infection likely to occur?
Contaminated or Traumatic Wound - 2 to 3 days
Surgical Wound - 4 to 5 days
Factors Impacting on Skin Integrity
Age, impaired mobility, nutrition, hydration, diminished sensation, impaired circulation, medications, moisture, fever, contamination or infection, lifestyle
How to clean a wound
top to bottom or from center outward, around drains from center outward in a circular motion
Vasodilation to increase blood flow & delivery of O2, nutrients, antibodies & leukocytes to the area
Types of heat therapy
Warm compress, warm soak, sitz bath, commercial hot pack, hot water bottle, heating pad
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