Wound Care And Pressure Sores Flashcards
Acute wound
Shows a progress of healing in a timely manner (completely heals)
Chronic wound
Does not show the progress of healing in a timely manner
Superficial wound
Extends through the epidermis
Deep wound
Extends through the dermis and subcutaneous tissue, sometimes may extend to the underlying fascia
Pressure ulcer
(Pressure sores of decubitus)
breakdown of the skin on which pressure is applied for a prolonged period of time without pressure relief
Stage 1 pressure ulcer
Non-blanchable erythema (would not turn white)
Stage 2 pressure ulcer
Partial thickness skin loss
Stage 3 pressure ulcer
Full-thickness skin loss
Stage 4 pressure ulcer
Full-thickness tissue loss
Wound location
Check anatomical locations as per the anatomical landmarks. For example heel, ankles, sacrum, and coccyx.
Wound size
- Check for wound length
- Check for wound width
- Check for wound depth
- Check for wound girth
When dressing has been applied to the wound, special care must be taken:
- Regular skin inspections
- Skin should be kept hydrated
- Frequently change the position as scheduled for the patient
- Check for pressure bearing areas (bony prominences)
- Instruct the patient to avoid lying on the wounded area
- If the patient is in a wheelchair, push-ups must be performed to release pressure off the pressure bearing areas
- Transfer the patient carefully
Brayden scale
Scale for predicting pressure ulcer risk
•O-23
•less than 9=very high risk
Shearing
Force generated when skin is moved against a fixed surface moving in an opposite direction to the surface skin. (I.e. sliding down/ around the bed) LIFT AND MOVE NOT PULL!
Common cause of pressure sores:
Friction of skin against the surface
