NURS 225 Lecture Notes - Lecture 6: Diabetic Neuropathy, Chronic Venous Insufficiency, Rheumatoid Arthritis
29 Mar 2020
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Clean technique: concerned with eliminating the spread of microorganisms. Sterile technique: concerned with keeping or eliminating all microorganisms from an object or area. Stage 1: reddened, irritated area that does not blanch when pressed (indicates compromised circulation) Stage 2: epidermal and dermal damage, pain, development of moisture and drainage. Stage 3: exudate present (slough), adipose tissue exposed and muscle tissue damage. Stage 4: bone exposure, muscle/tendon damage, slough present, undermining and tunneling may be present. Slough: creamy yellow exudate, which contains fibrin, bacteria, and neutrophils which adheres to the wound bed and prevents healing, which requires irrigation or debridement. Irrigation fluid: usually normal saline which irrigates the cleanest to the dirtiest area of the wound, and is irrigated until the fluid is clear. Normal saline soaked gauze: often used to pack complex wounds, and absorbs more exudate than dry gauze. Foam and alginate: used for large amounts of exudate, infected wounds, requires a secondary dressing.
