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In there is a red spot over a bony prominence that does not blanch, what stage ulcer is this?
If you find an ulcer that has gone through the dermis and epidermis What stage ulcer is this?
If you find an ulcer that tunnels and you can see bone and tendons, What stage ulcer is this?
If you find an ulcer that has full thickness tissue loss and can see fat, What stage is this?
What would you do nutritionally to encourage wound healing?
- Vitamin C- helps with collagen synthesis
- Vitamin E
- Maintain Hydration Status
- Protein before any surgery
What is hemorrhagic and what could cause it?
- Excessive bleeding
- Dislodging of a clot
- Bleeding under the skin.
- *Circle the border... look for expansion
A wound that starts to heal at top and bottom but reopens in the middle
When organs come out of a wound
A wound has yellow and watery fluid coming out... What kind of drainage is this?
A wound has pus coming out (white yellow or green)? What kind of drainage is this?
A wound has bloody drainage. What is this from? And What kind of drainage is this?
- From damage on the capillary level
If there is pink drainage, what kind drainage
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
What is a normal WBC count?
When there is an infection, What cell is high?
What protien helps promote healing?
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?
- 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?
- Meant to stay in place 3-5 days
- Meant to absorb fluid and drainage but also keep it moist
Clear absorbant acrylic is what?
- 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?
Uses topical enzyme or maggots to get rid of dead tissue
the removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument
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
- 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
What are some examples of dry cold
What are some examples of moist cold?