wounds

• inflammatory: 3-4 days
• proliferative: 4-21 days
• maturation: 3-4weeks

wound margins are neat, surgical incision or paper cut

• -trauma, ulceration infection
• - lots of exudate, wide irregular margins
• -can not be approximated
• -debris

• -delayed suturing of a wound in which 2 layers of gran tissue are sutured together
• -wound left open
• -large deep scar

nonblanchable erythema of skin intact

partial thickness skin loss involving the epidermis, dermis or both

full thickness skin loss involving damage to or necrosis of SQ tissue that may extend to but not go through fascia

full thickness skin loss w/ extensive destruction, tissue necrosis, damage to supporting muscle or bone or supporting structures

30-35cal/kg/day

1.25-1.5 g/kg/day

.8/kg/day

serum albumin

the best level is the pre albumin level

1000 mg/day

1600-2000

15-30 mg

30-35 ml/kg/day

bleeding from wound site

abnormal passage way b/t systems

separation of edges

seperation and organs protrude

• -adhesive
• -occlusive seal
• -moisture retaining
• -not for wounds w exudate

• stage I/II pressure ulcers
• skin tears
• cover iv and centrals

debrides wound mechanically if applied wet and allowed to partially dry

for cleaning, packing, covering

for big wounds

• thicker
• moisture
• absorption exudate
• 3-7 days

stage 3/4 pressure ulcers not infected

highly absorbent

grafts, burns, ulcers w/ heavy exudate, infected wounds

• JP
• Hemovac

penrose

• -draws neg pressure
• -closes wound
• -pulls blood and o2 to surface
• -pulls out exudate
• -debrides
• -DRESSING MUST BE SEALED

• autolytic-self
• sharp-surgical
• mechanical-scraping
• enzymatic-enzymes

• 9 or below- very high risk
• 10-12- high risk
• 13-14- moderate risk
• 15-18- at risk gen pop
• 13- at risk ICU