In there is a red spot over a bony prominence that does not blanch, what stage ulcer is this?
Stage 1
If you find an ulcer that has gone through the dermis and epidermis What stage ulcer is this?
Stage 2
If you find an ulcer that tunnels and you can see bone and tendons, What stage ulcer is this?
Stage 4
If you find an ulcer that has full thickness tissue loss and can see fat, What stage is this?
Stage 3
What would you do nutritionally to encourage wound healing?
Vitamin C- helps with collagen synthesis
Vitamin E
Zinc
Maintain Hydration Status
Protein before any surgery
What is hemorrhagic and what could cause it?
Excessive bleeding
Dislodging of a clot
Hematoma
Bleeding under the skin.
*Circle the border... look for expansion
Dehiscence
A wound that starts to heal at top and bottom but reopens in the middle
Evisceration
When organs come out of a wound
A wound has yellow and watery fluid coming out... What kind of drainage is this?
Serous
A wound has pus coming out (white yellow or green)? What kind of drainage is this?
Purulant
A wound has bloody drainage. What is this from? And What kind of drainage is this?
From damage on the capillary level
Sanguienous
If there is pink drainage, what kind drainage
Serosanguinous
What are some nursing diagnosis' for skin integrity and wound care?
•Risk for infection•Imbalanced nutrition: less than body requirements•Acute or chronic pain•Impaired physical mobility•Impaired skin integrity•Risk for impaired skin integrity•Ineffective tissue perfusion•Impaired tissue integrity
In the Norton scale a score 14 or less indicates what?
Pressure ulcer development
When should the patient have had a tetanus exam?
Within the last 5 years
What are 3 common sites of pressure ulcers
above the buttocks
Back of the head
Heels
What is a normal WBC count?
4500- 10000
When there is an infection, What cell is high?
Leukocytes
What protien helps promote healing?
Albumin
How often should you turn a patient with pressure ulcers?
Every 2 hours
Tegaderm is an example of what kind of wound dressing?
What stage ulcer would you use this on?
Why?
Transparent film
Stage 2
it is airtight and holds in moisture while minimizing infection
What is the purpose of an impregnated nonadherent wound dressing?
It is used for a wound that is draining alot. It is infused with saline to help drain moisture
What is an example of a hydrocolloid dressing?
DuoDerm
Meant to stay in place 3-5 days
Meant to absorb fluid and drainage but also keep it moist
Clear absorbant acrylic is what?
Dermabond
Clear liquid band aid used instead of sutures
What is the purpose of polyurathane foam?
Used around the site of a wound to collect excess drainage
What is alginate?
Seaweed and then a dry dressing on top of that?
Chemical debridment
Uses topical enzyme or maggots to get rid of dead tissue
Surgical debridment
the removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument
Mechanical debridment
want the dressing to adhere to the wound and pull dead tissue off.
What examples of dry heat?
heat packs
Hot water bottle
electric pads
Moist heat
compresses
soaks
Sitz Baths
A dehydrated patient has a wound What would be the best application of heat.... Moist or dry?
Warm moist heat does not promote sweating or insensible fluid loss