Jeannelle MacPherson - Pressure Ulcers/Wound Care - reducing amount of time of healing with wound care or turning and positioning every two hours

Pressure Ulcer Staging

Stage 3: full thickness loss of skin in which adipose tissue is visible but deeper tissue is not

Stage 4: full thickness skin and tissue loss with esposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the injury

Stage 2: partial thickness loss of skin with exposed dermis, wound bed is viable, pink/red, and moist.

Unstageable: full thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed because it is obscured by slough or eschar

Stage 1: intact skin with localized area of nonblanchable erythema

Deep Tissue Injury: intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, or purple discoloration

Prevention

Gel/low air loss mattresses

Pillows/Foam wedges

Skin moisturizers/protectants

Increase in fluids and nutrition

Prophylactic Alleyvn on bony prominences

Turning and Positioning every 2 hours

Treatments

Venellex

Santil

Silvedine

Vash

Therahoney

Wound Vacuums

Surgical Debridement

Alleyvns

Autolytic debridement

Hydrogel dressings

Alignate dressings

Packing with Curlex

Acetic acid

Education

PPE if needed

Education on what the treatments actually are

Contacting wound team as soon as a wound/pressure ulcer is found for best course of treatment

Clean (not sterile) environment

Callahan, B. (2019). Nursing: A concept-based approach to learning (Vol. 2). Boston, MA: Pearson.

Carpenito-Moyet, L. J. (2017). Nursing care plans: Transitional patient and family centered care (7th ed.). Wolters Kluwer Health.