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What are 4 factors that contribute to pressure ulcers?
- Mobility and Activity
- Intrinsic Factors
- Extrinsic Factors
What are intrinsic factors that contribute to pressure ulcers?
- Underlying health status
What extrinsic factors that contribute to pressure ulcers?
What do mobility and activity and sensation specifically contribute to?
Time and pressure
What do intrinsic and extrinsic factors contribute to?
What are characteristics of a stage 1 pressure ulcer?
- epidermis involved.
- Could be coccyx, heels.
- Tissue is swollen and congested
- blood supply is cut off
What are the characteristics of a stage 2 pressure ulcer?
- partial thickness loss
- open and shallow
- pink or red wound bed
- looks like an abrasion.
What are the characteristics of a stage 3 pressure ulcer?
- full thickness loss,
- necrosis of subQ layer
- extends but not through fascia.
- Undermining (pockets off to side) might be present
What are characteristics of a stage 4 pressure ulcer?
- full thickness
- through fascia
- sometimes might see bone. Rare but happens.
- Tissue necrosis.
What does the number on the Braden score signify?
The lower the score, the greater the risk someone is at for a pressure ulcer.
What are the SIX categories we assess in the Braden scale?
- Sensory Perception
- Friction & Shear
How do we begin to prevent pressure ulcers?
Create patient-centered goals
What is the nursing diagnosis associated with pressure ulcers?
Impaired skin integrity related to shearing/friction...
What is an integral part of the pressure ulcer planning process?
What are SIX nursing interventions related to pressure ulcers?
- Meticulous skin care and moisture control
- Adequate nutrition
- Frequent repositioning
- Therapeutic mattresses
- Client/family teaching
How do you evaluate if the pressure ulcer is healing?
- Physical signs of healing and the status of the pressure ulcer
- Client’s adaptation to the altered skin integrity
- Each intervention should be evaluated for its effectiveness.
- Plan of care is revised to reflect most beneficial actions.
- PUSH Tool-Pressure Ulcer Scale for Healing
What are SIX types of OPEN wounds?
What are THREE types of closed wounds?
How do we classify wounds by age?
acute and chronic
How would you describe acute wounds?
- Disruption in tissue
- Approximated-can push edges back together
How would you describe chronic wounds?
- Not healing
How do you classify a wound by it depth?
- Partial-epidermis and superficial dermis
- Full-gone through several layers
What are the THREE color classifications of a wound?
- Red=blood flow
- Yellow=caution, like a stoplight.Could mean healing or could mean slough or infection
- Black-needs to be debridement, enzymatic cream. Dead tissue. Needs to be gotten rid of.
What are factors that affect wound healing?
- Chronic health condition
What are some signs of a complicated healing wound?
- Evisceration-pop open and have protrusion of organs
- Fistula formation-will appear as tunneling
What are FOUR ways to describe wound drainage?
- Serous-straw colored fluid, yellowish, usually clear
- Sanguineous-straight blood
- Serosanguineous-combo of the two
- Purulent-thick, yellow, odor
What do we look for when assessing the wound bed?
- Wound dimensions (size and depth)
- Tunneling and undermining
- Bed texture
- Bed moisture
- Wound odor
- Margins and surrounding skin
When documenting a wound, what does W.O.U.N.D. stand for?
- Wound/ulcer location
- Ulcer category, stage, classification, depth
- Necrotic tissue
- Dimension and drainage
When documenting a wound, what does P.I.C.T.U.R.E. stand for?
- Color of wound bed
What nursing diagnoses do I need to remember in regards to wounds?
- Impaired Tissue Integrity
- Risk for Infection
- Disturbed Body Image
- DeficientKnowledge (wound care)
What are priorities for patient outcome and planning?
- Client’s identified needs
- Promoting wound healing
- Preventing infection
What should we never use when cleaning a wound?
Never use: Perioxide, Betadine or Dakin’s solution
What should we use when cleaning a wound?
Normal saline or commercial noncytoxic solution
What is the optimal pressure to use when cleaning a wound with irrigation?
8#/sq in of pressure.
What are FIVE different ways to debride a wound?