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
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
3
Q
Positioning
A
- Change positions every 1 to 2 hours