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stage 1 ulcer persistent red, blue or purple. No open skin. No blanching
stage 2 ulcer partial thickness skin loss, presents as abrasion or blister
stage 3 ulcer full thickness skin loss with damage or necrosis of subcutaneous, deep crater
stage 4 ulcer visible bones or tendons plus all of stage 3
Unstageable due to necrotic tissue, can't assess damage
T or F - a Stage 4 ulcer can heal and become a Stage 2 ulcer False
Name 2 scales that assess risk for developing pressure ulcers Braden and Norton
What are the risks for developing ulcers? Impaired sensory perception or mobility/ altered level of consciousness/ shear/friction/ moisture
When charting wounds, what information should be included? Location, color, size, depth, tunneling, undermining, stage, open or closed, exudate, pain level at site, tenderness
irrigation directed flow of water over wounds
Correct method of wound cleaning Refer to lab notes or lab manual
Types of drains for wounds Hemovac - vascular cavity Jackson Pratt-grenade bombs t tube-after removal of gallbladder or bileduct Penrose-after surgery or for draining abcess
Wound debridement - autolytic Wound is dressed and allowed to heal itself. Body uses own enzymes to break down necrotic tissue.
Wound debridement - enzymatic commercially available creams and meds. May cause a foul odor but is not infected
Wound debridement - Sharp surgical. Ouch!!
Wound debridement - mechanical Physically peel layers off by hand. gross.
R/Y/B color code system for wound management Red - healthy/ Yellow - wound is infected/ Black - necrotic.
Different types of dressings - know what and when to use gauze, transparent films, hydrocolloids, hydrogels, absorbent dressings. If anyone wants to make some cards here to give examples of each, feel free :)
Cold and Heat Therapy used for different injuries. See Lynn 420-427
Created by: Marshall3