Skin Integrity and Wound Care
Risk Factors for Pressure Ulcers
Friction and Shearing
Fecal and urinary incontinence
Decr. mental status
Excessive body heat
Risk Assessment Tools for Pressure Ulcers
Braden Scale for Predicting Pressure Sore Risk
Norton's Pressure Area Risk Assessment Form Scale
*Need consistency for trending and measuring
2 Layers: The Epidermis and Dermis
Pressure Ulcer (PU) Stage I
PU Stage II
Partial thickness skin loss
PU Stage III
Full thickness skin loss involving damage/necrosis to subcutaneous tissue
PU Stage IV
Full thickness skin loss + damage/necrosis to muscle, bone, or supporting structures
A bright red flush on the skin occurring after pressure is relieved (illustrates blood is still flowing to this area - no ischemia)
Confined to teh skin, that is, the dermis and epidermis; heal by regeneration
Involving the dermis, epidermis, and subcutaneous tissue, and possibly muscle and bone; require connective tissue repair.
Primary Intention Healing
Tissue surface approximated
Secondary Intention Healing
(inside -> out)
Edges cannot be approximated
Large tissue loss
Scarring is greater
Higher susceptibility to infection (open wound)
Tertiary Intention Healing
(Delayed primary intention)
Initially left open 3-5 days
Normally to to drainage or infection
Phases of Wound Healing
Proliferative (collagen synth and granulation tissue formation)
Maturation (organization/remodeling, scar stronger)
Purulent (yellow, pus)
Serosanguineous (watery + blood)
Purosanguineous (pus + blood)
How to measure Pressure Ulcer Depth
Parallel swabs used to measure wound depth
Obtain Wound Specimen from...
From base of the wound
*think in class they said, irrigate, then obtain specimen from inside granulated tissue
Preventing Pressure Ulcers
Reassess clients risk for all clients DAILY
Semi Fowlers preferred 45-60
Skin Cleansing Agents
Use "Mild" agents
Treating Pressure Ulcer
Never use alcohol or hydrogen peroxide
These are cytotoxic (they kill cells)
Provide devices to minimize pressure areas
RYB Color Guide Wound Care
Red = protect and cover
Yellow = cleanse
Black = Debride (remove the dead black necrotic flesh.. yum)
Wound Dressing for Pressure Ulcers
Clear absorbent acrylic
Tie Tapes - used to secure large dressing that require frequent changing - the tape has ties on it, so you don't have to remove and reapply tape a bunch (risk tearing the skin)
Incr. capillary permeability
Incr. cellular metabolism
Use Heat For...
Joint stiffness from arthritis
Low back pain
Decr. capillary permeability
Decr. cellular metabolism
Slows bacterial growth
Local anesthetic effect
Use Cold for...
Post-injury swelling and bleeding (contusions?)
Heat: 30-30 min (more = bad)
Cold: only until 15 degrees Celsius (60F)
When cleaning a drain (e.g., penrose)
Use circular movements.
Start around the drain and work your way out.
Precut gauze goes on afterwards
Hydrocolloid dressings protect shallow ulcers and maintain an appropriate healing environment
are used for wounds with significant drainage
Total of 23 Points.
Below 18 points is at risk.
Total of 24 Points.
15 or 16 are scores that indicate risk.
As the capillary network develops, the tissue becomes a translucent red color. The tissue, called granulation tissue, is fragile and bleeds easily.
Clean midpoint to outwards. Top to bottom. (book)
Partial or total rupturing of a sutured wound
The protrusion of the internal viscera through an incision
designed to increase blood circulation
Tighter at ankle, push blood back to the heart.
Delegation of Wound Care
You don't delegate wound care? Correct me on fb if this is wrong pls.
Care of contusions