pressure wound stages
Stage 1
nonblanchable, redness of intact skin
What happens in the hemostasis phase?
This occurs immediately after injury, and causes blood vessels to constrict.
Swelling, redness, pain, and warmth may occur during this phase.
What are the first 6 general steps when you enter a patients room before beginning the procedure?
Introduce yourself, provide privacy, perform hand hygiene, identify client, ask about allergies, explain and procedure
what is the fifth step in the wound care procedure?
Collect would culture
swab center of the wound and send it to the lab
Describe serous drainage
Clear, body fluid
partial thickness skin loss, shallow, open ulcer or blister formation
What happens during the inflammatory phase?
This is an immune system reaction to an injury and it protects the body from infection and expedites healing.
Involves white blood cells, neutrophils, lymphocytes, and macrophages.
First step in the demonstration of wound care procedure?
Gather supplies and place at bedside.
Supplies needed: measuring devices, sterile dressing change kit, sterile scissors, NS, sterile wound specimen culture, packing strips, cotton-tipped applicators, sterile gauze
What is the sixth step in the wound care procedure?
Prepare sterile field
open sterile kit, gently drop items on the sterile field, put on sterile gloves
Describe sanguineous drainage
Bright red, bleeding
stage 3
full thickness skin loss, no bone, tendon or muscle visible. May see subcutaneous fat
What happens during the Proliferative phase?
This stage restores skin integrity by filling the wound with new tissue. New blood vessels are formed within the would.
What is the second step in the wound care procedure?
Remove old dressing
This includes: moisten with NS, assess drainage, discard dressing.
What is the last step of the wound care procedure?
Pack the wound
using the cotton tipped applicator, pack tunneling with packing strip and leave a small tail.
Cover the wound with sterile ABD pad and secure with tape
Label dressing and wound specimen with patient, time, date, initials
Describe eschar tissue
black or brown in color, thicker in consistency
Stage 4
full thickness skin loss with bone, tendon, or muscle visible
What happens during the Maturation phase?
This phase completes the wound healing process. Remodeling works to reorganize collagen and Increases strength and skin integrity
What is the third step in the wound care procedure?
Measure the wound.
length, width, depth, tunneling/undermining
how early before procedure should you give pain medications?
30 minutes before
Describe slough tissue
lighter in color, usually yellow. Thiner consistency
unstageable
This is when a wound can not be determined because it's covered by slough or eschar in the wound bed.
In what phase does scaring begin to form?
The proliferative phase
The fourth step in the wound care procedure?
Irrigate the wound
using the syringe, pull up NS and irrigate the wound from top to bottom. Use gauze
Why is it important to be sterile for this procedure?
The patient could be at risk for infection.
describe serosanguineous drainage
serum and blood