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Stage 1 Pressure Ulcer
Intact skin with an area of persistent, non-blanchable redness, typically over a bony prominence, that may feel warm or cool to the touch. The tissue is swollen and congested, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple.
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Stage 2 Pressure Ulcer
Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage.
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Stage 3 Pressure Ulcer
Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common.
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Stage 4 Pressure Ulcer
Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar(black scab-like material), or slough(tan, yellow, or green scab-like material)
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RYB Color Code of Wounds
- Red- Healthy Regeneration of tissue
- Yellow- Presence of purulent drainage and slough
- Black- Presence of eschar that hinders healing and must be removed
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Goals of Wound Care for RYB color Code
- Red- Protect/Cover
- Yellow- Cleanse
- Black- Debride
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Preferred cleansing agents for wounds
Isotonic Solutions
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Transparent Film Dressing
- Provides protection against contamination and friction
- Maintain a clean moist surface that facilitates cellular migration
- Provide insulation by preventing fluid evaporation
- Facilitate wound assessment
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When to use Transparent Film Dressing
- IV dressing
- Central line Dressing
- Superficial Wounds
- Stage 1 Pressure Ulcers
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Impregnated Nonadherent Dressing
Cover, soothe, and protect partial- and full-thickness wounds without exudate
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When to use Impregnates Nonadherant Dressing
- Postoperative Dressing
- Over staples/sutures
- Superficial burns
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Hydrocolloid Dressing
- Absorb exudate
- Produce a moist environment that facilitates healing but does not cause maceration of surrounding skin
- Protect the wound from bacterial contamination, foreign debris, and urine or feces
- Prevent shearing
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When to use Hydrocolloid Dressing
- Stage 2-4 Pressure Ulcers
- Autolytic debridement of eschar
- Partial-Thickness Wounds
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Clear absorbant Acrylic Dressing
- Maintains a transparent membrane for easy wound bed assessment
- Provides bacterial and shearing protection
- Maintains moist wound healing
- Can be used with alginates to provide packing to deeper wound beds
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When to use Clear absorbant Acrylic Dressing
- Pressure Ulcers
- Skin tears
- Venous stasis ulcers
- Surgical Wounds
- Wounds undergoing chemical debridement agents
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Hydrogel Dressing
- Liquefy necrotic tissue or slough
- Rehydrate the wound bed
- Fill in dead space
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When to use Hydrogel Dressing
- Pressure Ulcers
- Skin Tears
- Partial-thickness wounds
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Polyurethane Foam Dressing
- Absorbs up to heavy amounts of exudate
- Provides and maintains moist wound healing
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When to use Polyurethane Foam Dressing
- Light to highly exudating wounds
- Pressure Ulcers
- Skin Tears
- Venous stasis Ulcers
- Surgical Wounds
- Wounds Undergoing chemical debridement agents
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Alginates(Exudate absorbers) Dressing
- Provide a moist wound surface by interacting with exudate to form a gelatinous mass
- Absorb Exudate
- Eliminate dead space or pack wounds
- Support debridement
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When to use Alginates Dressing
- Pressure Ulcers
- Skin tears
- Venous stasis ulcers
- Surgical wounds
- Wounds undergoing chemical debridement agents
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Dehiscence
Partial or total rupture of a sutured wound, usually with separation of underlying skin layers
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Evisceration
Dehiscence that involves the protrusion of visceral organs through a wound opening
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Sharp Debridement
Scalpel or scissors are used to separate and remove dead tissue
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Mechanical Debridement
Accomplished through scrubbing force or moist to moist dressing
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Chemical Debridement
Uses collagenase enzyme agents such as papain-urea
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Autolytic Debridement
Dressings that contain wound moisture, ie:hydrocolloid and clear absorbant acrylic dressings, to trap the wound drainage against the eschar. The body's own enzymes break down necrotic tissue. It takes longest but causes less damage.
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When to use heat application
- Relax muscle spasms and increase muscle contractility
- Soften exudates
- Relieve pain and provide comfort
- Increases joint ROM and reduces stiffness
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When to use cold application
- Relax muscles and decrease muscle contractility
- Reduce inflammation and decrease pain by slowing nerve conduction rate and blocking nerve impulses and causing numbness
- Decrease bleeding
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