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13 Cards in this Set

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PSST
Pressure Sore Status Tool
Measures 13 parameters and assigns a score to each
1) size (length times width)

(2) depth

(3) edges

(4) undermining

(5) necrotic tissue type

(6) necrotic tissue amount

(7) exudate type

(8) exudate amount

(9) skin color surrounding wound

(10) peripheral tissue edema

(11) peripheral tissue induration

(12) granulation tissue

(13) epithelialization
Braden Scale
Predicts pressure sore risk based on: Sensory Perception, moisture, activity, mobility, friction and shear, and nutrition
Chronic Pressure Ulcer Cleansing
Perform at every Dressing change Use Normal saline, ringers lactate or noncytotoxic cleanser
Chronic Pressure Ulcer Dressing
Hydrocolloid, Hydrogel, hydrofiber, foam, alginate, or silicone
Chronic Pressure Ulcer adjunctive treatments
radiant heat, hyperbaric oxygen, VAC, electric stimulation, ultrasound, ultraviolet light, pulsed EM fields
When are systemic antibiotics indicated for Chronic pressure ulcers?
Bacteremia, sepsis, advancing celllulitis, osteomyelitis
How often should patients with pressure ulcers be turned?
Every Two Hours
What growth factor can be used in a non-infected chronic diabetic ulcer?
Becaplermin
What off-loading techniques can be used with chronic diabetic ulcers?
Total contact cast, half shoe, walking brace, wedge shoe, shoe cutout
What should be used to remove slough in chronic venous ulcers?
Iodoflex
Adjunctive therapies for chronic venous ulcers
Hyperbaric oxygen, electrical stimulation, Ultrasound
What should be considered for chronic venous ulcers if patient cannot tolerate compression?
Pentoxifylline
Types of compression for chronic venous ulcers
Unna boot, unna+coban, setopress, Multilayer system, compression stockings Lymphedema wraps, Ace wraps