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WOUND CARE
- 5. On average*, a pressure ulcer 2.075 mm or deeper is classified at least as a Stage III. How thick is 2.075 mm? A plastic ruler A house key A U.S. Nickel
- 6. Localized area of tissue breakdown resulting from compression of soft tissue between a bony prominence and an external surface
- 100. MEASURING WOUNDS Use a single-use measuring guide.
- 102. Across longest and widest areas. Which is length? 12:00 6:00 3:00 9:00 Which is width?
- 138. TREATMENT OF WOUNDS
- 143. SURGICAL HERE SHOWING CALLUS REMOVAL
- 155. Eggs are off-white, and laid in clusters of 25-500. One-day-old larvae are only about 2 mm in length, and almost transparent. By the time the maggots are 3 or 4 days old, they have grown to about 1 cm (1/2 inch) long.
- 156. DAY 1 DAY 3 DAY 7
- 169. Shallow and Wet Shallow and Dry SHALLOW/SUPERFICIAL WOUNDS MODERATE – HEAVY EXUDATE Goals : Absorb exudates, maintain moist surface; support autolysis if necrotic tissue; protect and insulate Need : Absorptive cover dressing: Alginates, foam, gauze, hydrocolloid (if not too wet) SHALLOW/SUPERFICIAL WOUNDS MINIMAL OR NO EXUDATE Goal : Maintain or create moist surface; protect and insulate Need : Hydrating or moisture retentive cover dressing: Gels, hydrocolloids, transparent thin films, non-adherent gauze
- 171. SUMMARY
- 172. Deep and Wet Deep and Dry CAVITY WOUNDS MODERATE – HEAVY EXUDATE Goals : Fill dead space; absorb excess exudates; maintain moist wound surface; protect Need : Filler and cover dressing Fillers : alginates, gauze Cover : Gauze, ABD, transparent film, foam CAVITY WOUNDS MINIMAL OR NO EXUDATE Goals : Fill dead space; maintain moist wound; protect and insulate Need : Hydrating filler dressing; cover dressing Filler : Gel, damp gauze Cover : Gauze, ABD, transparent film, foam
- 174. THANK YOU
Editor's Notes
- Which is why surgical wounds dehisce in patients with a lot of adipose tissue
- Regardless of the specific name, this type of ulcer is defined as a localized area of tissue breakdown due to ischemia that develops when an area of soft tissue is compressed between skeletal bone and an external surface.
- Iceberg chosen to represent the Pressure ulcer elimination initiative. Much like an iceberg, the damage to the tissue is below the surface and what is visible on the surface may not reflect what is below the surface. Iceberg first used by Dr. Mary Foscue, Sacred Heart Pensacola. “ Pressure ulcers form when external pressure exceeds the tissue capillary pressure of 25 to 32 mm Hg. This pressure impedes blood flow for a period of time causing altered tissue perfusion or tissue ischemia, resulting in the formation of an ulcer. “(Armstrong) Armstrong Diana., Bortz Pamela. (2001) An Integrative Review of Pressure Relief in Surgical Patients (Electronic Version). AORN Journal March 2001., Volume 73, Number 3.
- Different types of tissues and cells have variable tolerances for ischemia and pressure. For example, muscle tissue is more sensitive to ischemia than the tissues of the skin; therefore by the time the skin shows visible signs of pressure damage, the underlying muscle tissues may already be necrotic. As external pressure from a surface is transmitted from the skin to the underlying bone, the bone exerts a counter pressure and all tissue layers in between are compressed to varying degrees. These opposing pressures create a cone shaped pressure gradient. One way to visualize this is to imagine the base of a triangle resting against the bony prominence with its point at the skin surface. The pressure generated from soft tissue compression is distributed within the triangle. The greatest pressure, represented by the base of the triangle, is placed on the bone and muscle layers. This pressure diminishes as it reaches the apex of the triangle or the skin. Therefore, the earliest and greatest damage occurs in the underlying tissues. It is estimated that 70% of a pressure ulcer lies beneath the skin – this is referred to as the iceberg effect . For this reason, pressure ulcers should always be assessed for undermining.
- Can be difficult to detect in patients with dark skin tones
- This stage is not used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation
- Eschar is tan, brown or black. Slough is yellow, tan, gray, green, or brown.
- Stable eschar on heels serves as “a natural cover” and should not be removed
- This is not for prevention but for treatment. A Tricell can only be ordered if pt already has Stage 3 or 4 pressure ulcers on the trunk only.
- The Braden tool assesses these six parameters. These six categories most commonly put a patient at risk for the development of pressure ulcers.
- The Braden tool assesses these six parameters. These six categories most commonly put a patient at risk for the development of pressure ulcers.
- Shear Friction in combination with gravity can produce shear forces. Gravity pulls down on the body and deeper tissues, while resistance or friction from the bed surface tends to hold the skin in place. This causes angulation, stretching, twisting, or even tearing of capillaries in the affected area, which leads to disruption of blood flow, ischemia, and cellular death. Shear forces can result in ischemia even more quickly than pressure. Think of how easy it is to stop the flow of water through your garden hose by kinking it as opposed to standing on it… Shearing forces most commonly occur when the head of the bed is elevated greater than 30 degrees and the patient slides down. Additional shearing and friction damage can be inflicted if caregivers use improper lifting techniques and drag the bedridden patient up to the head of the bed or across the surface of the bed.
- Sensory Moisture Activity Mobility Nutrition Friction
- There are many types of wounds that we encounter every day that are not related directly to pressure although this may be a factor in their development. Vascular wounds are a common problem in hospitalized patients. Their etiology is related to poor arterial or venous blood supply and present a challenge to the healthcare professional. Vascular wounds are usually seen on the lower extremities--toes, ankles, lower leg. It is important to be aware of their differences so that we can make good treatment choices.
- Any question whatsoever as to arterial flow, ABI’s or vascular studies must be done prior to compression