Wounds 2

Stage 1 Pressure Ulcer

  Unblanchable erythema, skin intact

Stage 2 Pressure Ulcer

Partial thickness involving the epidermis and dermis

Stage 3 Pressure Ulcer

Full thickness skin loss involving subcutaneous tissue

Stage 4 Pressure Ulcer

Full thickness tissue loss involving muscle, bone and supporting structures

Hemorrhage

• Dislodged clot

• Broken stitch

• Hematoma

• Internal Bleeding

Infection

• Pain

• Redness

• Fever

• Inflammation

• Increased WBC

• Foul odor

• Purulent drainage

Eschar

Layer of necrotic or dead tissue

• Debridement needed

Heat Therapy

• Vasodilation

• Increased capillary permeability

• Increased cellular metabolism

• Increased Inflammation

• Sedative effect

Cold Therapy

• Vasoconstriction

• Decreased capillary permeability

• Decreased cellular metabolism

• Slows bacterial growth

• Local anesthetic effect

Dehiscence

Partial or total separation of wound layers as a result of excessive stress on unhealed wounds

Evisceration

Most severe complication of dehiscence. Abdominal wound completely separates, with protrusion of visceral organs

• Risk: smoking, obesity, malnutrition, anticoagulants, excessive coughing

Braden scale Components

1. Sensory perception

2. Moisture

3. Activity

4. Mobility

5. Nutrition

6. Friction & Shear

Braden Scale

19-23 indicates no risk. Used to assess risk for pressure injury. Use on admission and daily

Rebound Phenonium

the opposite effect of heat or cold therapy occurs due to prolonged application.

• With heat, prolonged exposure causes blood vessels to constrict, reversing the intended vasodilation, and increasing burn risk because circulation is compromised.

• With cold, continuous application can cause a reflex vasodilation, potentially increasing swelling, after the initial vasoconstriction has peaked.