Wound Care

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176 Nurse to Nurse — Erythrocyte sedimentation rate (ESR) of 70 to 100 mm/hr is predictive of osteomyelitis. 14 — X-ray is not the best diagnostic tool — Bone biopsy is usually definitive — CT scan or Indium-111-labeled leukocyte scanning is definitive but costly — Treatment usually requires 4 to 6 weeks of antibiotic therapy (may be longer in some cases) Nursing Alert Treatment of moderate to severe infections should be evaluated immediately by a physician. — Treatment of infection may include: Systemic oral or intravenous antibiotics Debridement of necrotic tissue Incision and drainage, soft tissue/bone/joint resection Amputation • Eliminate weight bearing and pressure — Ideal is total removal of weight on foot and complete bed rest in recalcitrant wounds — “Healing” sandals or special shoes — Total contact casts — Removable walking casts • Correct ischemia — Hyperbaric oxygen therapy (not a substitute for revascularization) — Physician evaluation for revascularization • <strong>Wound</strong> care — Debridement as necessary (sharp or surgical); callus removal if necessary
Neuropathic and Diabetic Ulcer 177 — Dressings that provide warm, moist environment free from external contamination (saline, hydrocolloids, alginates, foams, films, and hydrogels) — Growth factors such as becaplermin (Regranex), a recombinant human platelet derived growth factor — Pressure reduction — Infection control — Control edema if present using elevation and paste wraps. Use the following only after consultation with the physician to be sure that the patient has adequate vasculature to support use of these products: elastic support stockings and pneumatic compression pumps • Manage gangrene — Dry gangrene: results from loss of nourishment to the tissues; black, shriveled, and mummified tissue with a specific well-defined line of demarcation; will autoamputate in many cases Painting with povidone iodine and allowing this to dry often prevents progression to wet gangrene. Protection from destructive forces of shear and/or friction is necessary. Obtain a physician order for any activity that causes moistening of dry gangrene; use caution in this situation. — Wet gangrene: caused by necrosis and destruction of tissue from excessive moisture; bacterial gases accumulate in the tissues; limb is usually painful, purple, and swollen without a well-defined line of demarcation; wet gangrene is almost always infected and requires surgical referral — Table 6–4 demonstrates the Wagner ulcer grading scale with corresponding treatment • Patient adherence with medical regimen including prevention strategies (Table 6–5):
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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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120 Nurse to Nurse Figure 4-4 Extre
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122 Nurse to Nurse • Provide thor
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124 Nurse to Nurse Table 4-5 Advant
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Page 180 and 181: 164 Nurse to Nurse • 5% to 10% of
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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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