Wound Management Adult Med
Terms
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- WOUND MANAGEMENT
- WOUND MANAGEMENT
- What causes a pressure (decubitus) ulcer
- impaired blood supply resulting from porlonged pressure over bony or cartilaginous prominences
- What are some differential diagnoses for pressure ulcers
- herpes, skin cancers, pyoderma gangrenosum and ecthymagangrenosum (ulcerating lesion due to pseudomonas)
- What methods are used fro prevention
- clean dry skin and linens, turned at least once hour, examine pressure points frequently, special mattresses and pads
- What does a stage 1 ulcer look like:
- Ill-defined area of intact skin with fixed erythema after pressure is relieved. may have a change in skin temp, tissue consistency firm or boggy, pain or itching. In light pigmented skin may appear red, in darker skin tones may appear red, blue, or purple.
- What does a stage 2 ucler look like:
- Partial thickness loss of epidermis or dermis. Ulcer is superficial and resembles blister, abrasion or shallow crater. Necrotic tissue may overlie ulcer.
- What does a stage 3 ulcer look like:
- Full thickness loss of epidermis and dermis with damage to underlying subQ fat. May extend to but not thru fascia.
- What does a stage 4 ulcer look like:
- Full thickness skin loss with extensive destruction, or tissue necrosis to bone, muscle, tendon or joint.
- What is a grade / stage 5 ulcer
- Closed cavity communicating thru a small sinus.
- What other staging systems are used to assess decubitus ulcers
- Yarkony-kirk has 6 stages. Pressure sore status tool 1-4 scale. Sessing scale 1-6. Wound healing scale uses letters, Nortonand Braden A&B scales predict.
- Describe chages in a wound that indicate infection
- warm or hot, red and swollen, possible fever, increased WBC. Infection is common among pt's with pressure ulcers which occationally lead to bacteremia, sepsis and death
- What mechanical forces can lead to pressure ulcers
- pressure, friction or shearing
- What does the Norton scale assess
- hysical condition, mental status, activity, mobility, and incontinent
- What does Braden scale assess
- sensory perception, skin moisture, physical activity, nutritional intake, friction and shear, and ability to change and control body position
- How would you treat a pressure ulcer
- decrease pressure, wound care and testing for osteomyelitis
- what are some symptoms specific to arterial ulcers
- diminished pulses, edema not generally present, skin t4emp decreased or cool, surroungding skin shiny taut thin dry, no hair on lower extremity, thick brittle toe nails. Painful and more severe
- What are some treatment considerations for arterial ulcers
- laser doppler to measure capillary refill, tcPO2, duplex scan, vascular consult, no smoking
- What does a venous ulcer look like
- color is yellow and sloughy, wound base fibrinous or granular, irregular margins, frequent edema, skin temp normal, surrounding skin may be brown with haemosiderosis staining.
- What are some treatments for venous ulcers
- improve venous return, multi-layer compression wraps, compression hose, leg elevation, compression devices
- What might a hx be for someone with a venous ulcer
- previous DVT or varicosities, decreased mobility, obesity, traumatic injury, fam hx, previous venous ulcer, pain when extremity is dependent, decreased pain with elevation
- What might a hx be for someone with an arterial ulcer
- smoking, DM, HTN, age, hx of arterial disease, intermittent claudication, px with elevation, improves with dependence