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21 Cards in this Set
- Front
- Back
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WOUND MANAGEMENT
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WOUND MANAGEMENT
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What causes a pressure (decubitus) ulcer
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impaired blood supply resulting from porlonged pressure over bony or cartilaginous prominences
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What are some differential diagnoses for pressure ulcers
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herpes, skin cancers, pyoderma gangrenosum and ecthymagangrenosum (ulcerating lesion due to pseudomonas)
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What methods are used fro prevention
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clean dry skin and linens, turned at least once hour, examine pressure points frequently, special mattresses and pads
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What does a stage 1 ulcer look like:
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Ill-defined area of intact skin with fixed erythema after pressure is relieved. may have a change in skin temp, tissue consistency firm or boggy, pain or itching. In light pigmented skin may appear red, in darker skin tones may appear red, blue, or purple.
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What does a stage 2 ucler look like:
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Partial thickness loss of epidermis or dermis. Ulcer is superficial and resembles blister, abrasion or shallow crater. Necrotic tissue may overlie ulcer.
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What does a stage 3 ulcer look like:
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Full thickness loss of epidermis and dermis with damage to underlying subQ fat. May extend to but not thru fascia.
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What does a stage 4 ulcer look like:
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Full thickness skin loss with extensive destruction, or tissue necrosis to bone, muscle, tendon or joint.
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What is a grade / stage 5 ulcer
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Closed cavity communicating thru a small sinus.
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What other staging systems are used to assess decubitus ulcers
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Yarkony-kirk has 6 stages. Pressure sore status tool 1-4 scale. Sessing scale 1-6. Wound healing scale uses letters, Nortonand Braden A&B scales predict.
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Describe chages in a wound that indicate infection
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warm or hot, red and swollen, possible fever, increased WBC. Infection is common among pt's with pressure ulcers which occationally lead to bacteremia, sepsis and death
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What mechanical forces can lead to pressure ulcers
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pressure, friction or shearing
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What does the Norton scale assess
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hysical condition, mental status, activity, mobility, and incontinent
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What does Braden scale assess
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sensory perception, skin moisture, physical activity, nutritional intake, friction and shear, and ability to change and control body position
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How would you treat a pressure ulcer
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decrease pressure, wound care and testing for osteomyelitis
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what are some symptoms specific to arterial ulcers
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diminished pulses, edema not generally present, skin t4emp decreased or cool, surroungding skin shiny taut thin dry, no hair on lower extremity, thick brittle toe nails. Painful and more severe
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What are some treatment considerations for arterial ulcers
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laser doppler to measure capillary refill, tcPO2, duplex scan, vascular consult, no smoking
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What does a venous ulcer look like
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color is yellow and sloughy, wound base fibrinous or granular, irregular margins, frequent edema, skin temp normal, surrounding skin may be brown with haemosiderosis staining.
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What are some treatments for venous ulcers
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improve venous return, multi-layer compression wraps, compression hose, leg elevation, compression devices
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What might a hx be for someone with a venous ulcer
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previous DVT or varicosities, decreased mobility, obesity, traumatic injury, fam hx, previous venous ulcer, pain when extremity is dependent, decreased pain with elevation
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What might a hx be for someone with an arterial ulcer
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smoking, DM, HTN, age, hx of arterial disease, intermittent claudication, px with elevation, improves with dependence
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