Wound Drainage Types and Devices
- Serous
- Serosanguineous
- Sanguineous
- Purulent
- T-tube
- Penrose
- Jackson-Pratt (JP)
- Hemovac
- Record Drainage Amounts
- Check Device Function
Types of Wound Healing
- Acute
- Chronic
- Primary Intention
- Approximated Edges
- Secondary Intention
- Edges Not Approximated
- Tertiary Intention
- Delayed Closure due to Infection and Necrosis
Braden Scale
- Sensory Perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and Shear
Interventions for Impaired Skin Integrity
- Signs of Skin Breakdown
- Pain
- Redness
- Decreased Skin Turgor
- Bleeding
- Bony Prominences
- Reposition Q2H
- Pressure Relief
- Maintain Clean and Dry Skin
- Adequate Nutrition and Hydration
Pressure Ulcers
- Prolonged Immobilization
- Neurologic Disease
- Decreased Level of Consciousness
- Stage 1: Intact Skin with Non-blanchable Erythema
- Stage 2: Partial Thickness Skin Loss
- Stage 3: Full-thickness Skin Loss without Fascial Involvement
- Stage 4: Full-thickness Skin Loss with Fascial Involvement
- Wound Care
- Surgery
- Septicemia
- Osteomyelitis
- Prevention
Stevens-Johnson Syndrome
- Drugs
- < 10% of Body Surface Area (BSA) Involved
- 10-30% BSA Overlaps with Toxic Epidermal Necrolysis (TEN)
- Fever
- Affects Skin and Mucous Membranes
- Bullae Formation
- Necrosis
- Sloughing of Skin
- High Mortality Rate
- Supportive Care
- IVIG (Intravenous Immunoglobulin)
Necrotizing Fasciitis Pathophysiology and Characteristics
- Bacterial Infection of Muscle Fascia and Subcutaneous Fat
- Polymicrobial or Monomicrobial
- Polymicrobial: Anaerobe + Gram Negative Enterobacteriaceae
- Monomicrobial: Group A Streptococcus or Staph Aureus
- Edema Extending Beyond Erythema
- Crepitus
- Pain Out of Proportion (POOP)
- Anesthesia Over Affected Area (Late Finding)