ASSESSMENT
Follows the parallel plane of the wound opening leaving it bigger under the surface.
What is undermining?
One option to treatment denuded skin caused by exposure to urine, feces, body fluids, wound exudate, or friction?
Apply Barrier Cream
Length X width X depth using correct anatomical position.
Diabetes
Obesity
Poor Nutrition
Elderly
What are some barriers to wound healing?
You see dry, thick, leathery tissue, often tan brown or black
What is eschar
A narrow tract extending into the depth of the tissue from any portion of the wound.
What is tunneling?
One of the following choices okay
Nonadherent dressing and cover dressing/wrap
Silicone foam dressing and cover dressing/wrap
Xeroform dressing and cover dressing/wrap
Bacitracin and cover dressing/wrap
What types of wounds do we stage?
Only Pressure Injuries
What is the largest organ of the human body?
Skin
Suspected Deep Tissue Injury and Stage 1 pressure injury the same?
No
Injury exposing underlying muscle, tendon cartilage or bone.
What is Pressure Injury Stage 4
How often should we change a skin tear dressing?
About 3 days - as infrequently as possible but changing before it becomes dry and adheres to the wound.
Can we reverse stage wounds?
Ex. patient admitted with stage 3 pressure injury wound couple days later it looks like stage 2, but can we call it stage 2?
No
Patient from OR with inpatient VAC ULTA wound vac, but provider wants to transfer patient with the machine can patient leave with the machine?
NO, patient can not leave with the wound vacs
Patient will need another dressing placed
You see wrinkly, soft wet soggy skin around a wound
What is maceration
Pressure injury wound bed covered in yellow slough, what stage is it?
Unstageable because we don't know the full tissue involvement.
At least a stage 3 or 4. No slough in stage 2.
Physician would like wound vac dressing applied to a wound, you see bone and tendon exposed what do you cover with?
Protection dressing - a non-adherent dressing
What is Medical Terminology for:
Front
Back
Outer side of body
Near the middle of body
Front - Anterior
Back - Posterior
Outer side of body - Lateral
Near the middle of body - Medial
Orders:
Non-weight bearing
Keep dressing clean dry and intact
Will do dressing self
Call if dressing gets wet
What are podiatrist wound orders?
What is IAD?
Incontinence Associated Dermatitis
DEEP purples, maroon or red intact tissue over a bony prominence.
What is suspected deep tissue injury?
Allergies to silver and sulfadiazine.
Contraindications to use silvadene cream
Three of the following
Description of wound bed
Drainage color
Drainage amount
What the surrounding tissue looks like
Location
Measurements
What are the goals of palliative wound care or comfort care patients?
Management of:
Pain
Odor
Dignity
Drainage
Prevention (as able) of infection and new wounds
Patient with stable, non infected dry eschar to both heels can we start removing the eschar?
No
We only do prevention for now