Pressure Wounds

Question 1

Cleaning wounds

Answer 1

• 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

Question 2

Stages

Answer 2

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

Question 3

Positioning

Answer 3

• Change positions every 1 to 2 hours