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17 Cards in this Set
- Front
- Back
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Prevention of pressure ulcers |
Assess nutrition: albumin, CBC, hydration status, intake, weight, BMI. Supplement with high protein.
Position appropriately. |
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Braden scale |
predicts ulcer risk |
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Wound exudate |
Eschar: necrotic tissue. Slough: yellow or white tissue that adheres to ulcer bed. Granualation tissue: pink or beefy red tissue with shiny, moist, granular appearance. Epithelial tissue: looks like new pink or shiny tissue that grows in from the edges. Closed: new skin or epithelium |
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Debriedment stages |
Hydrogels/Hydrocolloid dressings: Do not use with high exudate wounds. Can be used for many wound types: pressure ulcers, burns, macerated skin, fistula, stoma.
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Granulation stage |
Foam dressing works well with high-exudate wounds. Low adherence of foam dressing decreases wound trauma (dressing changes). Can be left in place for 3-4 days. Tegaderm, Oposite Wounds: leg ulcers, pressure ulcers, skin graft donor sites, minor burns, diabetic ulcers.
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Epithelialization Stage |
Hydrocolloid and low-adherance dressings are used. |
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Types of wound Dressings for Pressure Ulcers |
Page 420 |
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Sharp Debridement |
Tools: Scalpel or scissors and forceps Gently lift negrotic tissue and cut it |
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Enzymatic Debridment |
Topical proteolytic enzymes: Collagenase, fibrinolysin, deoxyribonuclease. Apply to pressure ulcer |
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Autolytic debridement |
Cover with hydrogel or semi-occlusive transparent film. Works better in wounds with little to no discharge. |
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Jet lavage |
Water is used under pressure to clean and debride wound. A large syringe is connected to a short tube with a silicone needle tip. |
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Complications: Pressure ulcers |
#1: Local infection (proteous miribilis, group D streptococci, E Coli, staph, pseudomonas, corynebacteriam organisms). May spread to surrounding skin (cellulitis) or bone (osteomyelitis) and body (sepsis).
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Superficial pressure ulcer infection treatmetn |
Better wound care, debriedment. No dine preps to ulcer wound because they impede healing. Trial of topical antibiotics for 2 weeks (abx ointment or Silver sulfadiazine 1% cream) Culture needs to be deep tissue specimen taken by wound biopsy or needle aspiration. |
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Osteomylitis |
Refer for hospitalization for IVABX. Order plain xray- may need CD or MRI if positive xray. Blood cultures, ESR, CRP, WBC, bone biopsy for C&S. |
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Marjolin Ulcer |
Rare, malignant transformation of a chronic wound or scar. Very aggressive form of squamous cell carcinoma. Need a tissue biopsy from the ulcer and refer to Derm. |
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Wound healing |
Primary: closure within 24 hours by sutures, glue, or adhesive strips. Secondary: left open with formation of granulation tissue and scarring. Heals from bottom up. Edges are not well approximated. Tertiary: heavy contaminated wounds or crush injuries are best left open to heal by secondary intention (granulation) and wound contraction. Then edges are approximated in 3-4 days. |
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High risk wounds |
Infection (leave open for 24 hours, heals by secondary intention, abx - Keflex or Doxy) Closed fist (ED for xray to rule out foreign body or fracture, test pulses, abx if animal bite: Augmentin, tetanus vac) Facial Foreign body (high risk of infection, needs xray) Joint capsule Electrical Paint guns, high pressure wounds Chemical Abuse Cartilage. |
