Question | Answer |
Venous Insufficiency wound
Draining pressure ulcer
1st and 2nd degree burns | Semipermeable foam (Allevyn)
P/C Nonadhesive foams should be used on patients with fragile skin; Use skin sealant to prevent maceration
CI: Dry or eschar-covered wounds; arterial ulcers; heel ulcers |
CI/PC for Venous Insufficiency wound | Concomitant arterial disease
Allergic reactions and sensitization
Inappropriate whirlpool use |
Rationsle for use of semipermeable foam dressing on draining wound | VI wound is draining and must absorb some of the drainage and maintain a warm moist environment. Too much drainage can result of periwound maceration and create a larger wound, so it needs to be controlled by using a semipermeable foam dressing. |
CI/PC for pressure ulcer | Control pressure and sheer forces
Control moisture to prevent maceration
Make sure it is hydrated |
Arterial Insufficiency
Non-draining pressure ulcer | Hydrogel
P/C Use skin sealant to prevent maceration; time the sheet hydrogel to the size of the wound
CI: Do not use on heavily drainining wounds; bleeding wounds; sheet hydrogels on infected wounds;
Gauze (telfa) |
Rationale for use of hydrogel | Hyrdogel provide a dry wound bed with moisture. Facilitates normal wound healing. Traps enzymes within the wound bed, facilitating autolytic debridement. Preserves growth factors, cytokines, promote cell growth, fibroblast prolif & collagen synthesis |
CI/PC for arterial insufficiency ulcers | Avoid compression and compression dressings
Avoid sharp debridement of dry, eschar-covered, uninfected ulcers in patient with low ABIs
Grangrenous tissue must be removed surgically |
Neuropathic Ulcer | Semipermeable foam (Allevyn)
P/C Nonadhesive foams should be used on patients with fragile skin; Use skin sealant to prevent maceration
CI: Dry or eschar-covered wounds; arterial ulcers; heel ulcers |
Raationale for use of Allyvn on Neuropathic Ulcer | Maintain a moist environment to Facilitate normal wound healing. Traps enzymes within the wound bed, facilitating autolytic debridement. Preserves growth factors, cytokines, promote cell growth, fibroblast prolif & collagen synthesis |
CI/PC for Neuropathic Ulcer | Monitor signs for hypoglycemia
Educate foot guidelines
proper foot wear |
Burns CI/PC | Prevent complications
Contractions, infections, deconditioning, pulmonary dysfunction, pressure ulcers;
Do not allow burn surfaces to touch one another, protect from friction |
Burns 3rd degree | Impregnated Gauze Dressing (Adaptic)
P/C Venous insufficiency ulcers |
Rationale for adaptic on 3 degree burns | Help decrease trauma to wound bed during dressing changes, increase occlusiveness of gauze dressing |
PC/CI telfa | Tefla used for superficial, non-draining wounds closed by primary or secondary intention, so do not use on more significant wounds may cause maceration and larger wound size |