Pressure Wounds Flashcards

1
Q

Cleaning wounds

A
  • use a 30-60 mL syringe with an 18-19 gauge catheter to deliver the ideal pressure of 8lbs per square inch when irrigating the wound (0.9% normal saline)
  • wounds that are developing granulation tissue should have a hydrocolloid dressing and transparent film dressing
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2
Q

Stages

A

Stage I:
- non-blanchable erythema of intact skin (skin does not turn white when applying pressure)
- NON-BLANCHABLE - it does not turn white when you press on it
- Skin is still intact

Stage II:
- partial-thickness skin loss with exposed dermis, and presents as a shallow open ulcer with a red pink wound
- very red and surrounded by blisters.
- abrasion, blister, or shallow crater

Stage III:
- full-thickness skin loss; open ulcer or blister; not involving underlying fascia

Stage IV:
- full-thickness skin and tissue loss; exposed cartilage, bone, ligament, tendon, fascia

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3
Q

Positioning

A
  • Change positions every 1 to 2 hours
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