CNUR 103 Lecture Notes - Lecture 7: Pressure Ulcer, Asepsis, Anaerobic Respiration
11 Feb 2020
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Cnur 103 notes week 7 (skin integrity and pressure ulcers) 30-60 minutes before performing a dressing change, assess pain level and administer pain med order: stages of ulcer development, stage 1 no broken skin, redness, change of colour does not fade or turn white when pressed. Tx: pressure off, good hygiene, mild soapy water, pat dry, be gentle. Adequate protein/calories: stage 2 epidermis broken, shallow open sore. May/may not have drainage that presents edema, heat. Tx: same steps as stage 1 not use normal saline instead of soapy water and apply a dressing: stage 3 skin broken through to dermis and into sq. deeper and drainage occurs. Tx: same as stage 1 & 2 but need additional wound care and different packing: stage 4 broken down into muscle/bone. Tx: surgery: assessment of skin integrity, hx and physical exam, skin diseases, previous bruising, general skin condition, skin lesions, usual healing of sores.
