Decubitus Ulcers and Burns - Chapter 40 Flashcards
1
Q
Decubitus Ulcer
A
- A pressure sore or bedsore
- Most commonly occur over bony prominences
- Tissue begins to decay from lack of blood circulation
2
Q
Stages of Wounds
A
-1, 2, 3, 4
3
Q
Stage 1 Wounds
A
- Surface reddening of skin
- Skin is unbroken
- Wound is superficial
4
Q
Stage 2 Wounds
A
- Blister, broken or unbroken
- Partial layer of skin is injured
- Goals: cover, protect, and clean the area
5
Q
Stage 3 Wounds
A
- Wound extends through all layers of skin
- Risk of serious infection
- Goals: alleviate pressure, cover and protect wound
6
Q
Stage 4 Wounds
A
- Extend through the skin and involve underlying muscle, tendon and bone
- Can produce life threatening infection; must treat very quickly and aggressively
7
Q
Prevention of Decubitus Ulcers
A
- Most important principle is preventing initial skin damage
- Frequent turning of patients
- Maintain hydration
- Good hygiene
- Applying skin protection
8
Q
Treatment of Decubitus Ulcers
A
- Keeping area clean
- Removing dead tissue
- Exudate control
- Using topical treatments for healing of partial-thickness sores
- Possibly surgery
9
Q
Keeping Area Clean
A
-Use sterile water or normal saline
10
Q
Debridement (Removing Dead Tissue)
A
-collagenase breaks down collagen into gelatin
11
Q
Exudate Control
A
- Occlusive, hydrocolloid dressing to promote fibrinolysis, angiogenesis and wound healing without softening or breaking down tissue
- Duoderm, Tegaderm, Aquacel
12
Q
Topical Antiinfectives
A
- bacitracin
- gentamicin
- mupirocin
13
Q
Burns
A
-A thermal injury or lesion
14
Q
Burn Classifications
A
- First degree
- Second degree
- Third degree
- Fourth degree
15
Q
First Degree Burn
A
-Minor discomfort, reddening of skin; tissue injury minimal
