Week 5: Complex Wounds Flashcards
Decubitus Ulcers
known as pressure ulcers
often over bony prominences
How do the stages work when referring to pressure ulcers
1-4 are the layers of the skin
(epidermis, dermis, subcutaneous tissue, and bone/muscles)
What kind of wound environment should we provide?
moist as an eye
What temperature should we maintain the wound?
at body temperature
it takes about 12 hours to get the wound back to body temperature
Suspected deep tissue injury
when there is non visible damage to the subcutaneous tissue or bone/muscle
only see a bruise like appearance and usually happens with a sheering injury
Stage 1 : Epidermis
Skin is intact
Look at bony prominences
get pressure off by moving the patient
Stage 2: Dermis
Shallow, open ulcer
red, pink wound bed
No slough
can be intact to open with blister
Stage 3: Subcutaneous
yellow/translucent fat may be visible
full thickness tissue loss
slough may be present but no bone/muscle showing
Stage 4: Bone/Muscle
Full thickness tissue
exposed bone, tendon, muscle
Slough or eschar present
What is the best dressing to use on skin tears
if it’s not bleeding too much is Tegaderm Absorbent
(can be left on for a month) (also used on stage 2)
Why are women 3x more likely to have venous leg ulcers
because of pregnancy
Venous leg ulcers
caused by venous insufficiency
being overweight, older, sitting in the same position too long
All the fluid builds up and will explode/open to allow the release of fluid
Hemosiderin Straining - Skin Changes
Hemoglobin in the blood (red staining)
Astrophie Blanche- Skin Changes
White patches
Lipodematosclerosis - Skin Changes
Inverted bottle shape (fat is hard)
