Wound Care

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170 Nurse to Nurse Table 6–1 Wagner Scale for Grading Neuropathic Ulcers Grade Description Grade 0 Skin intact Grade 1 Superficial ulcer Grade 2 Deeper ulcer to tendon or bone Grade 3 Ulcer has abscess or osteomyelitis Grade 4 Gangrene on forefoot Grade 5 Gangrene over major portion of foot Reproduced with permission from Wagner FEW: The dysvascular foot: a system for diagnosis and treatment. Foot and Ankle. 2:64–122. Copyright © 2008 by the American Orthopaedic Foot and Ankle Society, Inc. • The Wagner scale helps the clinician effectively grade neuropathic ulcers (Table 6-1). Other physical assessment techniques include: • Check vital signs and report hypertension — Report any findings that fall outside of baseline • Check pedal and post tibial pulses • Check foot and limb warmth • Check blood sugar levels since last visit • Assess patient and caregiver education regarding daily foot care and response • Perform wound care with very clean technique • Be sure to thoroughly document all of this information in the patient record Treatment and Management The nurse relies on collaboration with the multidisciplinary team to assist in the treatment and management of neuropathic/ diabetic ulcers. It is important that the nurse clearly documents each treatment and related evaluation to help the health-care team formulate and execute an effective plan of care (POC).
Neuropathic and Diabetic Ulcer 171 Nursing Alert It is of extreme importance to treat immediately any minor injuries or trauma in the neuropathic (and often diabetic) foot to prevent further tissue damage. Lack of recognition of the injury or injury type and inappropriate treatment or delay in treatment can lead to amputation. The primary treatment goals in managing neuropathic/ diabetic ulcers are to prevent limb loss and maintain quality of life. The nurse works to prevent limb loss and to maintain the patient’s quality of life through: • Appropriate screening and examination • Prevention measures to avoid ulceration and recurrence • Early recognition and treatment of diabetic/neuropathic foot complications • Patient and caregiver education of the above • Table 6–2 summarizes the evaluation, assessment, and management of diabetic ulcers • The nurse obtains explicit orders for off-loading from the physician including: — Total nonweightbearing, crutches, bedrest, or wheelchair — Total contact casting — Foot casts or boots — Removable walking braces with rocker bottom soles — Total contact orthoses; custom walking braces — Patellar tendon-bearing braces — Half shoes or wedge shoes — Healing sandal; surgical shoe with molded plastizote insole or insert — Accommodative dressings: felt, foam, or felted foam — Shoe cutouts (toe box, medial, lateral, or dorsal pressure points)
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Nurse to Nurse WOUND CARE
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Nurse to Nurse WOUND CARE Donna Sce
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Professional Want to learn more? We
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xii List of Acronyms RBC Red blood
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2 Nurse to Nurse THE ROLE OF ETHICS
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4 Nurse to Nurse — Who does not h
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6 Nurse to Nurse • Specific amoun
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8 Nurse to Nurse disclosure of info
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10 Nurse to Nurse Remember Doing go
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12 Nurse to Nurse or guarantee anyt
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14 Nurse to Nurse Remember Provide
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16 Nurse to Nurse evaluation and ca
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18 Nurse to Nurse • The Hastings
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20 Nurse to Nurse Jacobs BB, Taylor
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22 Nurse to Nurse KEY POINTS • Su
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24 Nurse to Nurse Hair follicle Seb
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26 Nurse to Nurse Table 2-1 Common
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28 Nurse to Nurse — Brands of lig
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30 Nurse to Nurse • Acute wound:
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32 Nurse to Nurse Explicit chemoatt
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34 Nurse to Nurse • Diabetic foot
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36 Nurse to Nurse healing. This pha
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38 Nurse to Nurse or staples may be
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40 Nurse to Nurse increase in tempe
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42 Nurse to Nurse º If the wound i
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44 Nurse to Nurse º Linear wounds
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46 Nurse to Nurse Trauma Patient/ca
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48 Nurse to Nurse º Poor protein i
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50 Nurse to Nurse — Vitamin A: me
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52 Nurse to Nurse MULTIDISCIPLINARY
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54 Nurse to Nurse • Refer the pat
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58 Nurse to Nurse KEY POINTS • De
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Head Bony prominence Shoulder Sacru
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62 Nurse to Nurse • The proposed
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64 Nurse to Nurse Epidermis Muscle
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66 Nurse to Nurse Non blanchable er
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68 Nurse to Nurse — High intensit
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70 Nurse to Nurse • Elevated temp
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72 Nurse to Nurse • Corn starch s
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74 Nurse to Nurse • Diet and flui
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76 Nurse to Nurse — Occupational
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78 Nurse to Nurse — Use antifunga
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80 Nurse to Nurse — Keep the woun
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82 Nurse to Nurse • Stage III —
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84 Nurse to Nurse Apply hydrogel di
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86 Nurse to Nurse • The word “p
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88 Nurse to Nurse Table 3-3 Compone
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90 Nurse to Nurse Table 3-5 Categor
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92 Nurse to Nurse • Risk for pres
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94 Nurse to Nurse — If patient ha
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96 Nurse to Nurse • The Hartford
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98 Nurse to Nurse Hall JC. Sauer’
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100 Nurse to Nurse KEY POINTS • V
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102 Nurse to Nurse Deep leg veins E
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104 Nurse to Nurse Muscle contracti
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106 Nurse to Nurse • Trap hypothe
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108 Nurse to Nurse • Varicose vei
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110 Nurse to Nurse Nursing Alert A
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112 Nurse to Nurse formation due to
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114 Nurse to Nurse Measure 5 centim
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116 Nurse to Nurse • Some studies
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118 Nurse to Nurse — Stockings ar
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Page 216 and 217: 200 Nurse to Nurse KEY POINTS • C
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220 Nurse to Nurse • In individua
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222 Nurse to Nurse • Usually star
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224 Nurse to Nurse 3. Pruitt BA, Le
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228 Nurse to Nurse KEY POINTS • E
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230 Nurse to Nurse functional outco
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232 Nurse to Nurse — Phase change
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234 Nurse to Nurse — Provided is
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236 Nurse to Nurse • Support clie
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238 Nurse to Nurse º Dressings* º
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240 Nurse to Nurse include the CNA
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242 Nurse to Nurse client and careg
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244 Nurse to Nurse the health-care
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246 Nurse to Nurse — Consistency:
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248 Nurse to Nurse Only when perfor
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250 Nurse to Nurse • Certain woun
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252 Nurse to Nurse — Safe to use
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254 Nurse to Nurse — Wound contam
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Table 9-2 CDC Criteria for Surgical
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258 Nurse to Nurse Infected wounds:
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260 Nurse to Nurse smaller wound di
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262 Nurse to Nurse — Delayed heal
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264 Nurse to Nurse of any injury to
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266 Nurse to Nurse — In the early
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268 Nurse to Nurse Table 9-3 Indica
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276 Nurse to Nurse Table 9-13 Indic
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278 Nurse to Nurse Table 9-16 Advan
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282 Nurse to Nurse Table 9-21 Indic
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288 Nurse to Nurse • Stage IV: fu
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290 Nurse to Nurse Shows 30° sidel
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292 Nurse to Nurse Slide hand (palm
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294 Nurse to Nurse — Appropriate
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296 Nurse to Nurse — Diet and flu
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298 Nurse to Nurse — Home rehabil
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300 Nurse to Nurse Pressure Ulcer T
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302 Nurse to Nurse • Home rehabil
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304 Nurse to Nurse • Diabetes nur
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306 Nurse to Nurse — Two (2) inch
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308 Nurse to Nurse weight distribut
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310 Nurse to Nurse — Gravitationa
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312 Nurse to Nurse Hill-Rom Huntlei
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314 Nurse to Nurse • Cleanse gent
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316 Nurse to Nurse — Avoid use of
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318 Nurse to Nurse Cunningham D. Tr
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322 Nurse to Nurse KEY POINTS • S
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324 Nurse to Nurse with the ability
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326 Nurse to Nurse º Tensile stren
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328 Nurse to Nurse Melanocytes tran
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330 Nurse to Nurse PATIENT HISTORY
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332 Nurse to Nurse — Often darker
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334 Nurse to Nurse — Any changes
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336 Nurse to Nurse — Any thyroid
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338 Nurse to Nurse — The sclera m
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340 Nurse to Nurse • Symmetry, ul
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342 Nurse to Nurse • Senile lenti
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344 Nurse to Nurse • Document the
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346 Nurse to Nurse 9 O’ Clock Rig
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348 Nurse to Nurse Nursing Alert Al
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350 Nurse to Nurse • Provide supp
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352 Nurse to Nurse Whenever the pat
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356 Index Arterial ulcer, 33 Arteri
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358 Index Debridement (Cont.): cuta
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360 Index Hematopoietic system, in
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362 Index Multizoned support surfac
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364 Index Pressure ulcers (Cont.):
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366 Index Skin temperature, in lowe
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368 Index Wheelchair positioning, 9
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Wound Care

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