Wound & Ostomy Flashcards
What dressing do you use when treating a “wet” wound
calcium alginate dressing (pulls moisture out of wound)
What dressing do you use for necrotic wounds?
Silver (silfazorb/methylex AG)
What dressing do you use for infected wounds?
Notify team of infection, same as wet/necrotic wounds
How do you dress deep wounds?
wet to dry dressing, soaking gauze w/ norm saline. pack with antiseptic gauze
Pressure injury is caused from
ischemia (disrupted blood flow) to an area so that the tissue dies
Shear vs. Friction injuries
Shear: When skin is stuck to mattress and skin stays when pt moves. Friction: when sheets cause an abrasion on the skin
One of the number one ways to prevent pressure injury
stage the body correctly
Stage one pressure injury looks like…
non-blanchable, over bony prominence
Stage two pressure injury look like…
Without slough open/ruptured serum filled OR serum filled bullas
Stage three pressure injury look like…
No bone or muscle/tendon visible. Skin curls at edges of wound
Stage four pressure injury look like…
You can see bone/muscle/tendon and tunneling
How do you measure a wound?
Measure first top-bottom then side-side. Use measuring tape to measure how long a tunnel is. Use a q-tip to go in and measure depth of tunnel
What do deep tissue injuries look like?
Dark, bruise like with no blanching -. May also look like blood-filled blisters
Mepilex dressinings are
5 layer foam dressings that reduce friction/shear
Mepilex dressings good for how long?
72 hours as long as they are not soiled