Cardio 3 4

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Author:
jld15
ID:
305717
Filename:
Cardio 3 4
Updated:
2015-07-26 08:34:00
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Cardio
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Description:
Cardio 3 4
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  1. Dimensions
    • Tunneling – narrow passage way created by defect in fascial plane
    • Undermining – Tissue under wound edge becomes eroded
    • Bed texture and moisture
  2. Wound odor
    • assess after wound has been debrided and rinsed
    • Pseudomonas – sickly sweet.
  3. Wound Picture
    • W – wound or ulcer location
    • O -odor
    • U –ulcer category, stage or classification
    • N –necrotic tissue
    • D – dimensions and drainage
    • P - pain
    • I – induration (raised and hard)
    • C -color
    • T - tunneling
    • U - undermining
    • R - reddness
    • E - edge
  4. Prevelence of pressure ulcer
    • Highest in acute care and long term care.
    • Quadriplegia 60%
    • Femoral Fracture 66%
  5. Pressure Ulcer
    • Tissue load caused by:
    • ---Pressure
    • ---Friction
    • ---Shear/ and exacerbated by moisture and temperature.
    • medicare pays based on stage
  6. New System – International NPUAP/EPUAP Pressure Ulcer Classification System
    • Stage 1 – non blanchable erythema of intact skin. Area may be warmer, cooler, firmer, softer, compared to adjacent area.
    • Stage II – superficial ulcer that presents as shallow crater without slough or bruising. May be ruptured, or intact (fluid or blood filled blister).
    • ---Partial thickness ulcer involving epidermis, dermis, or both.
    • Stage III – deep ulcer that presents as deep crater, may have undermining or tunneling.
    • ---Full thickness skin loss involving the epidermis, dermis, and subcutaneous tissue. Bone/tendon are not visible or palpable.
    • Stage IV – Deep ulcer with extensive necrosis, often has undermining or sinus tracts.
    • ---Full thickness skin loss involving the epidermis, dermis, subcutaneous tissue, fascia, and underlying structures such as muscle, tendon, joint capsule or bone.
    • Unstageable/Unclassified – a pressure ulcer should be described as unstageable if the base is obscured by eschar or slough.
    • ---Full thickness
    • ---Will be category III or IV
    • Suspected deep tissue injury – local area of purple or maroon discoloration of intact skin or blood filled blister.
    • ---Area may have been painful, firm, mushy, boggy, or warmer or cooler than surrounding tissue.
  7. Pressure Ulcer Risk Factors
    • - Decreased Mobility
    • - Impaired Cognition
    • - Poor Nutrition
    • - Incontinence
    • ---Impaired Sensation
    • ---Advanced age
    • ---Previous pressure ulcer
  8. Pressure Ulcer Risk Assessment Tools
    • Norton- 5 categories – physical condition, mental condition, activity, mobility, incontinence. Good/ slightly limited, lower scores mean higher risk
    • Braden – lower score greater risk; used most often
    • Gosnell- mental status, continence, mobility, activity, nutrition (1-5) higher score is greater risk.
  9. PUSH- Pressure Ulcer Scale for Healing Score based on:
    • Surface area
    • Drainage
    • Tissue type
  10. Sessing Scale
    • 7 point observational scale that describes wound and periwound.
    • Higher scores mean more severe pressure ulcer
    • Score of “0” means normal skin at risk
    • One minute to complete.
  11. Bates – Jenson Wound Assessment Tool - BWAT
    • Includes 13 items describing wound and periwound characteristics, size, depth, edges, undermining, necrotic tissue amount, exudate (drainage) and amount, skin color, tissue edema, induration(hardening as a result of inflammation), granulation, epithelialization.
    • 10 minutes to complete
    • Valid and reliable
    • Ability to respond to changes in ulcer status not yet assessed in literature.
  12. Prevention
    • Recognize risk and intervene
    • PT consult for:
    • ---Positioning
    • ---Mobility
    • ---Education
    • -------Blood sugar
    • -------incontience
  13. PT Interventions
    • Wound care/ debridement, dressings, pulsed lavage, wound vac
    • Recommend pressure reducing devices/wc cushions, specialty bed
    • Positioning and positioning schedules
    • NO DONUTS
    • Exercise to strengthen patient to improve mobility/flexibility ex
    • Functional training/transfers, gait
    • Electrotherapy – electrical stimulation

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