Denise Shared "Wound Care" - 17 Picmonics
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Wound Care
Braden Scale
- Characteristics
- Sensory Perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and Shear
2 mins
Interventions for Impaired Skin Integrity
- Assessment
- Signs of Skin Breakdown
- Pain
- Redness
- Decreased Skin Turgor
- Bleeding
- Bony Prominences
- Intervention
- Reposition Q2H
- Pressure Relief
- Maintain Clean and Dry Skin
- Adequate Nutrition and Hydration
2 mins
Pressure Ulcers
- Risk Factors
- Prolonged Immobilization
- Neurologic Disease
- Decreased Level of Consciousness
- Classification
- Stage 1: Intact Skin with Non-blanchable Erythema
- Stage 2: Partial Thickness Skin Loss
- Stage 3: Full-thickness Skin Loss without Fascial Involvement
- Stage 4: Full-thickness Skin Loss with Fascial Involvement
- Management
- Wound Care
- Surgery
- Considerations
- Septicemia
- Osteomyelitis
- Prevention
3 mins
Types of Wound Healing
- Types of Wounds
- Acute
- Chronic
- Healing Process
- Primary Intention
- Approximated Edges
- Secondary Intention
- Edges Not Approximated
- Tertiary Intention
- Delayed Closure due to Infection and Necrosis
2 mins
Wound Drainage Types and Devices
- Drainage Types
- Serous
- Serosanguineous
- Sanguineous
- Purulent
- Drainage Devices
- T-tube
- Penrose
- Jackson-Pratt (JP)
- Hemovac
- Considerations
- Record Drainage Amounts
- Check Device Function
2 mins
Chronic Venous Insufficiency (Venous Stasis Ulcer) Interventions
- Frequently Elevate Legs
- Avoid Standing/Sitting for Long Periods of Time
- Elastic Compression Stockings
- Bilayer Artificial Skin
- Daflon
- Wound Dressings
- Proper Foot and Leg Care
2 mins
Phases of Wound Healing
- Inflammatory Phase
- Inflammatory Phase up to Day 3
- Clot formation
- Neutrophil Migration
- Macrophages Clear Debris
- Proliferative Phase Day 3- weeks
- Mediated by Fibroblasts, myofibroblasts, endothelial cells, keratinocytes, macrophages
- Granulation Tissue, Collagen, angiogenesis, wound contraction
- Remodeling
- Variable 1-6 Months
- Mediated by Fibroblasts
- Type III Collagen Replaced by Type I
Debrid/e
- meaning
- Open a Wound
55 secs
Wound Healing 1: Inflammatory Phase
- Up to 3 days after wound
- Mediators
- Platelets
- Neutrophils
- Macrophages
- Characteristics
- Clot formation
- Increased vessel permeability leads to neutrophil migration
- Macrophages clear debris
- Macrophages and platelets secrete PDGF
Wound Healing 2-3: Proliferative and Remodeling
- Proliferative Phase
- Day 3- weeks
- Fibroblasts
- Myofibroblasts
- Endothelial cells
- Keratinocytes
- Macrophages
- Deposition of Type III collagen
- Deposition of granulation tissue
- Wound contraction
- Metalloproteinases encourage myofibroblast ativity
- Angiogenesis (days4-5)
- VEGF Increases vascular permeability
- Remodeling Phase
- Weeks-months
- Mediated by fibroblasts
- Metalloproteinases encourage remodeling
- Type III collagen replaced by type I Collagen
- Integrin-Fibronectin interaction--> signals that modulate growth, migration, etc
Post-Op Wound Complications
- Hematoma
- Increased risk with obesity and anticoagulation
- Ice packs, compression
- Surgery if in neck
- Seroma
- Results from disruption of lymph vessels
- Most self-resolve in 6 weeks
- Superficial Infection
- Prevent with ABX 1 hour pre-op
- Wound culture
- Dehiscence
- May feel popping sensation
- Fascial dehiscence: "salmon" colored drainage
- Early recognition: Return to OR to close
- Late recognition: allow to heal by granulation
- Enterocutaneous Fistula
- TPN
- Most self resolve
- Surgery if not closed in 6 months
- Necrotizing Fasciitis
Immobility
- Assessment
- Mobility Continuum
- Complications
- Cardiovascular
- Respiratory
- Musculoskeletal
- Integumentary
- Gastrointestinal
- Urinary
- Considerations
- Turn, Cough, Deep Breathe (TCDB)
- Range of Motion (ROM)
- Skin Care
- Fluids
- Balanced Diet
2 mins
WBC Differential Lab Value
- White Blood Cells (WBC)
- 5-10 (5,000-10,000)
- Leukocyte Differential
- Neutrophils (50%-70%)
- Bands (2%-5%)
- Segs (50%-70%)
- Lymphocytes (20%-40%)
- Monocytes (4%-8%)
- Eosinophils (2%-4%)
- Basophils (0.5%-1.5%)
2 mins
Red Blood Cell Count (RBC) Lab Values
- Women: 3.5-5.5 million cells/ MuL
- Men: 4.3-5.9 million cells/ MuL
1 min
Hemoglobin (Hgb) Lab Values
- Men: 13 - 17 g/dL
- Women: 12 - 16 g/dL
47 secs
Hematocrit (Hct) Lab Values
- Women: 36% - 46%
- Men: 41% - 53%
1 min
Platelet Lab Value
- 150,000-400,000 Micro L
40 secs
