Wound Care

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346 Nurse to Nurse 9 O’ Clock Right side Long axis 12 O’ Clock 6 O’ Clock Horizontal axis 3 O’ Clock Left side Figure 10–1 Wound Size. (Adapted with permission from Baranoski S, Ayello E. Wound Care Essentials Practice Principles. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.) — Describe the overall wound shape: oval, elliptical, or irregular — Wound length in centimeters with length according to patient head to foot location — Wound width in centimeters with width according to patient arm to arm location — Wound depth (may vary throughout the wound) in centimeters
Skin Assessment and Documentation 347 — Wound edges or margins: rolled, punched out, irregular, or macerated — Undermining: tissue destruction extending under intact skin along the periphery of a wound or tunneling; course or path of tissue destruction occurring in any direction from the surface or edge of the wound; results in dead space with potential for abscess formation; may have both at the same time. • Tissue type and amount — The amount should indicate the percent of the wound bed and edges that are of a specific tissue type. For example: 50% granulation tissue and 50% thin, yellow, fibrous slough. — Granulation — Slough — Eschar • Exudate — Amount on the dressing within 24 hours or since the last dressing change; indicate when the last dressing change occurred. — Color: serous, sero-sanguinous, or purulent — Odor: none, mild, or foul — Consistency: thin or thick • Surrounding or periwound skin — Intact — Macerated — Erythematous • Stage of pressure ulcers — Stage I — Stage II — Stage III — Stage IV — Unstageable
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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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196 Nurse to Nurse Bryant RA. Acute
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200 Nurse to Nurse KEY POINTS • C
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202 Nurse to Nurse • Solitary les
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204 Nurse to Nurse — Place a shal
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206 Nurse to Nurse All these agents
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208 Nurse to Nurse º These product
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210 Nurse to Nurse Abnormal lung fu
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212 Nurse to Nurse — No sun expos
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214 Nurse to Nurse — Specific ref
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216 Nurse to Nurse • Treatment
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218 Nurse to Nurse (systemic lupus
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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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278 Nurse to Nurse Table 9-16 Advan
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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
Page 312 and 313: 296 Nurse to Nurse — Diet and flu
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Page 318 and 319: 302 Nurse to Nurse • Home rehabil
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Page 338 and 339: 322 Nurse to Nurse KEY POINTS • S
Page 340 and 341: 324 Nurse to Nurse with the ability
Page 342 and 343: 326 Nurse to Nurse º Tensile stren
Page 344 and 345: 328 Nurse to Nurse Melanocytes tran
Page 346 and 347: 330 Nurse to Nurse PATIENT HISTORY
Page 348 and 349: 332 Nurse to Nurse — Often darker
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Page 372 and 373: 356 Index Arterial ulcer, 33 Arteri
Page 374 and 375: 358 Index Debridement (Cont.): cuta
Page 376 and 377: 360 Index Hematopoietic system, in
Page 378 and 379: 362 Index Multizoned support surfac
Page 380 and 381: 364 Index Pressure ulcers (Cont.):
Page 382 and 383: 366 Index Skin temperature, in lowe
Page 384 and 385: 368 Index Wheelchair positioning, 9
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Wound Care

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