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shmvii
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Braden scale, Norton scale, look at what?
risk assessment for pressure ulcers (bedsores, decubitus ulcers, trophic ulcers)
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stage 1 ulcer
- nonblanchable erythema
- reversible
- may have discoloration, warmth, edema, induration
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induration def
firming, hardening of tissues 2/2 edema
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stage 2 ulcer
- partial thickness skin loss
- epidermis and dermis are involved
- looks like an abrasion, blister, shallow crater
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stage 3 ulcer
full thickness going into fat layer / subcutaneous tissue, but not into fascia
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stage 4 ulcer
- full thickness, goes beyond fascia into muscle
- tendons, capsule may be exposed
- may include bone destruction
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unstageable ulcer
refers to an ulcer that is obscured by necrotic tissue
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treatment for stage 1
vigorous pressure, friction, and moisture alleviating measures
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stage 2 treatment
- dressing to occlude the wound
- and relieve pressure, friction, moisture like for stage 1
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stage 3 treatment
debridement, dressings, pressure alleviation
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stage 4 treatment
- debridement, dressings, pressure alleviation,
- surgery and grafting as needed
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arterial insufficiency ulcers -- usually located where?
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ABI < what means an arterial insuff ulcer needs surgery or meds
0.5
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treatment for arterial insuff ulcers
rest, elevate head of bed, stop smoking, ROM, wound VAC
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venous insuff ulcer location
medial malleolus
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Wagner scale is for what
diabletic foot ulcers -- for these wounds you can't use a pressure ulcer scale
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zone of coagulation
- cells are irreversibly damaged
- skin death
a term from burn wounds
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zone of stasis
injured cells that may die in 1-2 days if there's no specialized treatment
a term from burn wounds
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zone of hyperemia
- site of minimal cell damage
- tissue should recover within a week w/o lasting effects
a term from burn wounds
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1st degree burn
- superficial burn
- damage to epidermis only (sunburn)
- should heal in 2-5 days
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less severe 2nd degree burn
- superficial partial-thickness
- damage to epidermis and upper layers of dermis
- healing in 7-10 days w/o intervention
- may have minimal scarring
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more severe 2nd degree burn
- deep partial thickness
- most of dermis is destroyed
- injury to hair follicles, nerve endings, sweat glands
- looks red or white, edema, blisters, severe pain
- healing in 3-5 weeks
- hypertrophic and keloid scarring
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3rd degree burn
- full thickness
- destruction of epidermis, dermis, subcutaneous tissues, muscles
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4th degree burn
- subdermal
- destruction of epidermis, dermis, subcutaneous tissues
- involves bone and muscle
- amputation and paralysis are common
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Lund-Browder
classification system for extent of body that is impacted by a burn
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some antibacterial agents often used for burn woulnds
- nitrofurazone / Furacin
- silver sulfadiazine / Slivadene
- mafenide acetate / Sulfamylon
- Bacitracin
- Neosporin
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cyclosporine
- an immonosuppressive drug
- used when an allograft is given
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zenograft / heterograft
comes from another species
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split thickness grat
contains epidermis and upper layers of dermis
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full thickness graft
contains epidermis and dermis
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