(^410) Medical-Surgical Nursing Demystified
- Stage II:
- Opening in the skin with surrounding erythema from pressure
- Stage III:
- The ulcer is deep, down to the dermis, with red base and some drainage
- Stage IV:
- A deep ulcer involving muscle and bone, with visible signs of tissue death
INTERPRETING TEST RESULTS
- Culture to check for bacteria content.
- CBC to evaluate the hemoglobin and hematocrit for oxygen-carrying capa-
bilities. - Albumin and pre-albumin levels to check on nutrition.
- Chemistry to evaluate fluid status.
TREATMENT
Treatment is based on relieving pressure and providing adequate nutrition. Wound
treatment is aimed at preventing infection and encouraging healing. Stage I and
stage II wounds may heal with conservative treatments. However, stage III and stage
IV wounds often require surgical debridement and skin grafting. Treatment choice
depends on the stage of the wound.- Clean wound with soap and water or saline.
- Debridement to clean away dead, devitalized, and infected tissue. Debridement
methods include surgery, topical enzymatics, and mechanical debridement. - Dressings to protect the wound and keep it moist, which promotes healing.
- Hydrocolloids which keep moisture in.
- Nonadherant dressings, such as aquaphor.
- Bulk dressings to absorb copious drainage.
- Semipermeable dressings which allow for transfer of gases but are imper-
meable to liquids. - Antibiotic ointment for infected wounds.
- Oral antibiotics.
- Specialized matresses.
- Whirlpool treatments.