Wound Care

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246 Nurse to Nurse — Consistency: thick, thin, or purulent (yellow, green, or brown; white blood cells and cellular debris and dead organisms; color may suggest type of infecting organism) — Amount (refers to amount on primary dressing between dressing changes – primary dressing is what is actually on the wound surface; secondary dressing is what may be covering the primary dressing i.e. wound packed with 1-inch calcium alginate packing and covered with 4 4 gauze) None 0%–25% = small amount 26%–50% = moderate amount 51%–75% = large amount 76%–100% = copious amount — Odor: None Mild Foul — Surrounding (AKA periwound) skin: Intact/clear Macerated ______ Erythematous _______ Edematous ______ Indurated ______ Dry/flaky ______ Other: ___________ — Wound margins/edges: Attached (edges are attached to the sides of wound entire circumference) Not attached _____________ Edges rolled _____________ Sutures/staples intact
Wound Management, Products, and Support Surface Selection 247 Surgical incision approximated Surgical incision open ______ Epithelialization present ______ cm Epithelialization not present — Necrotic/devitalized tissue: Not present Present Type º Yellow slough º Black º Soft º Hard º Stringy º Other % of wound with necrotic/devitalized tissue º 100% º 75% º 50% º 25% º Other: ___% — Wound/tissue bed: Granulation tissue not present Granulation tissue __% Moist Dry — Neovascularization (blood vessels are visible/present): Present Not present — Tenderness or pain: — 0–10 scale (0 = no pain) On touch Anytime
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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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126 Nurse to Nurse Table 4-8 Indica
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128 Nurse to Nurse Table 4-10 Indic
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130 Nurse to Nurse • Treatment fo
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132 Nurse to Nurse Seaman S. Evalua
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134 Nurse to Nurse KEY POINTS • F
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136 Nurse to Nurse Chronic pain and
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138 Nurse to Nurse Aorta Superficia
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140 Nurse to Nurse Tunica initima E
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142 Nurse to Nurse Morphologically,
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144 Nurse to Nurse Carotid bifurcat
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146 Nurse to Nurse — These patien
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148 Nurse to Nurse ischemia from th
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150 Nurse to Nurse Table 5-1 Relati
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152 Nurse to Nurse DIAGNOSTIC PROCE
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154 Nurse to Nurse — Paint with a
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156 Nurse to Nurse º Enhanced work
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158 Nurse to Nurse • Cleanse gent
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160 Nurse to Nurse Hilleman D. Mana
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162 Nurse to Nurse KEY POINTS • P
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164 Nurse to Nurse • 5% to 10% of
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166 Nurse to Nurse — Hypertrophy
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168 Nurse to Nurse Symptoms include
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170 Nurse to Nurse Table 6-1 Wagner
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172 Nurse to Nurse Table 6-2 Evalua
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174 Nurse to Nurse — Antimicrobia
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176 Nurse to Nurse — Erythrocyte
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178 Nurse to Nurse Table 6-4 Wagner
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180 Nurse to Nurse 3. Armstrong DG,
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182 Nurse to Nurse Mayfield JA, Rei
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184 Nurse to Nurse KEY POINTS • L
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186 Nurse to Nurse — The most com
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188 Nurse to Nurse Yoga, meditation
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190 Nurse to Nurse MANAGEMENT AND T
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192 Nurse to Nurse Nursing Tip If t
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194 Nurse to Nurse — Contraindica
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Page 216 and 217: 200 Nurse to Nurse KEY POINTS • C
Page 218 and 219: 202 Nurse to Nurse • Solitary les
Page 220 and 221: 204 Nurse to Nurse — Place a shal
Page 222 and 223: 206 Nurse to Nurse All these agents
Page 224 and 225: 208 Nurse to Nurse º These product
Page 226 and 227: 210 Nurse to Nurse Abnormal lung fu
Page 228 and 229: 212 Nurse to Nurse — No sun expos
Page 230 and 231: 214 Nurse to Nurse — Specific ref
Page 232 and 233: 216 Nurse to Nurse • Treatment
Page 234 and 235: 218 Nurse to Nurse (systemic lupus
Page 236 and 237: 220 Nurse to Nurse • In individua
Page 238 and 239: 222 Nurse to Nurse • Usually star
Page 240 and 241: 224 Nurse to Nurse 3. Pruitt BA, Le
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Page 244 and 245: 228 Nurse to Nurse KEY POINTS • E
Page 246 and 247: 230 Nurse to Nurse functional outco
Page 248 and 249: 232 Nurse to Nurse — Phase change
Page 250 and 251: 234 Nurse to Nurse — Provided is
Page 252 and 253: 236 Nurse to Nurse • Support clie
Page 254 and 255: 238 Nurse to Nurse º Dressings* º
Page 256 and 257: 240 Nurse to Nurse include the CNA
Page 258 and 259: 242 Nurse to Nurse client and careg
Page 260 and 261: 244 Nurse to Nurse the health-care
Page 264 and 265: 248 Nurse to Nurse Only when perfor
Page 266 and 267: 250 Nurse to Nurse • Certain woun
Page 268 and 269: 252 Nurse to Nurse — Safe to use
Page 270 and 271: 254 Nurse to Nurse — Wound contam
Page 272 and 273: Table 9-2 CDC Criteria for Surgical
Page 274 and 275: 258 Nurse to Nurse Infected wounds:
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Page 280 and 281: 264 Nurse to Nurse of any injury to
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Page 294 and 295: 278 Nurse to Nurse Table 9-16 Advan
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Page 306 and 307: 290 Nurse to Nurse Shows 30° sidel
Page 308 and 309: 292 Nurse to Nurse Slide hand (palm
Page 310 and 311: 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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