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Pressure- relief devices.

Pressure-relief devices are useful for patients with complete immobility

and limited caregiver assistance. Pressure-relief device for example , air fluidixed therapy)
maintain pressures below capillary closing pressures. The oatient essentialy floats on a fluid
medium that distributespressure evenly. The patient home must have approate electrical outlets
and structural support because these beds are electric and may weigh 2000 pounds are more.
Additional costs of these surfaces should also be a consideration because the continued use at
electrical service will be realized in the patientselectric bill. Air flotation beds may render
patient management at home easier for elderly care givers who have difficulty meeting the
demands of a frequent turning schedule and may be more cost-effective in wound management
of certain patiens. Patients on airfluidized therapy should be well hyrdrate because this treatment
can cause dehydration increasing water loss through the skin and respiratory tissues.
Current philosophies of wound care blend the newwith the old. Frequent position changes, use of
medical equipment, application of cornstracrh based powder on the bed, use of transparent
adhesive, films or hydrocolloid dressings over areas at risk for breakdown, limiting the head of
the bed position to 30 degrees to preventshearing, incontinence management, and good nutrition
all promote wound healing. However, the question of what dressing is appropriate for what
wound is necessary to consider.
Specific therapy : matching wounds to treatments and products
Treatment for all types of wound should primariy be guided by four goals.
1. Prevention of further tissue destruction by reducing or controlling predisposing cause of
tissues destruction
2. Preventation of infection
3. Planning treatment as appropriate for (a) the type of chronic wound
(pressure,venous,arterial and (b) the condition and size of the wound (stage,amount of
drainage, and related factors)
4. Patient/caregiver preferences for care and babilities for self- care

Recommendation for specific therapy of chronis first begin with discussion of assessment
findings and treatment options with the patent/caregiver, and physician. Decide among all that
will work best in order to mutually determine a plan of care, incluidingnwound treatment
protocols thet the patient /caregiver is willing and able to follow. Spesicific treatment guidelines
as follows :
Stage 1 : nonblanchable erythema of intact skin
Interventions and spesifics reatment prevention use pressure reduction techniques along with
application of transparent adhesive films to protect renddened areas of skin at risk for
breakdown (Box 14-6). Institute skin care rgimen for stages I to IV. Condition is reversible with
promp intervention
Stage II : partial theicness wound

intervention and specific treatment : clean/protect. gently cleanse/irigate the wound bed with
physiological or detergent solution. application of a hydrocolloid dressing, transparent adhesive
film. foam,topical moisturizer, or impregnated gauze dressing will maintain a moist environment
for healing and protect the wound environmental contamintation
stage III : full thickness wound : shallow
interventions and specific treatment :debride/absorb/protect. Filled with easchar, slough, and
copious exudate, these wounds are often-infected. Use a physiological solution to cleans and
irrigate. A diluted concentration of an antiseptic or aseptic solution may be useful when working
with highly infected wounds. However,as healthy tssue (red) appears, to home care nurse is
strongly urged to switch to a physiological solution for cleansing and irrigation because
antiseptic and aseptic solutions are cytotoxic
debride the wound as order by the physician. Eliminate dead space in the wound with an
absorber (foam or granules or light packing with moistened gauze dressing) and cover with a
secondary protective dressing. Calcium alginate dressings may help control excessive drainage.
Avoid solitary use of transparent adhesive films or hydrocolloid dressings: these will not fill dead
space. Consult with the physician;antibiotic therapyeither systemic or topical ( silver sulfadiazine
cream) may also be useful. In addition,negative pressure wound therapy may be helpul to control
copious drainage that does not respond to other therapies

stage IV :full thickness wound : deep

intervaention and specific treatments :essentially same as for stage III
VENOUS STATIS ULCERS. Treatment should control edema and promote healing. Underlying
medical and nutritional disordes should be corrected. For example, congestive heart failure
should be controlled to reduce lower-extremity edema .if obesity is present, a weight reduction
program should be mitiated.
Periodically elvating the legs above the level of the heart with the use of compression theraphy
will control edema. Examples of compression theraphy include comprssion stockings, elastic
wraps, and the Unna boot. Instruc the patient to put compression stocking or Ted Hose on before
getting out of the bed in the morning. Compression stockings are to be worn all day. Elastic
wraps or bandages should be placed on the leg when edema is minimal inorder to maximaze
compression and venous return. Likewise, the application of a compression dressing such as the
Unna boot is helful to control edema.
A hydrocolloid dressing over the ulcer in combination with an impregnated gauze dressing or a
hydrocolloid- based elastic bandage may also prevent edema and promote healing. In addition,
calcium alginate-based compression dressings have been shown to be beneficial, because they
pick up exudates and absorb drainage yet maintain a moist environment for wounds that are at
risk for macertaio. Follow suggested interventions for stage II wounds

Arterial and diabetic ulcers. Arterial and diabetic ulcers are difficult to treat because of their
relatively ischemic state. Wound management should be directed toward the following :

Avoiding excessive pressue to the area by total non-weight-bearing or coorective

Cleansing/debriding the wound ( consult with the physician regarding debriding agent;
debridement is contraindicated in the presence of gangrene because removal of eschar
results in an open wound with impaired blood flow and susceptibility to infection : in this
case surgical intervention is strongly recommended
Preventing infection
Supporting the patient( encourage good nutrition, control edema, and control disease
process-blood glucose and blood pressure)

Compession therapy is genelly contraindicated in patients with an ischemic injury. Tight,

restrictive clothing or iil-fitting shoes should also be avoided
Because diabetic patients tend to lose sensation in the feet. Improper weight distribution and
subsequent tissue destruction may occur. Orthotics are specially fitted shoes designed to prevent
such traumatic ulceration. In addition total contact cats or below the knee plaster casts with
minimal padding over bony prominences may be used to reduce forces of shearing and pressure
in noninfected ulcers. Trauma must be avoided
Activities will likely be limited for patients with peripheral vascular disease if the ulcer is to
receive maximal perfusion. Patients with diabetes should never use hot water bottles or foot
soaks to warm upthe feet because warmth increased the demand for blood. If neuropathy s
present with arterial in sufficiency and this increased demand for blood cannot be met, tissue
injury results. (refer to chapter 15 ; pay close attention to recommendations for diabetic foot
care) utmost emphasis should be place on theaching the patient to seek care for even the smallest
The use of topical antibacterials and systemic antibiotic to treat an ischemic ulcer varies among
practitioners. Although a topical antibacterial may help control infection, systematic antibiotics
may not reach the wound bed because of poor circulation. Topical medications that contain
steroids are not recommended because they trigger vasoconstriction
Patient with ischemic ulcers are at tremendous risk for gangrene and lower extremity amputation
aseptic technique in dressing changes is advised and often difficult for the patient /caregiver to
learn. Therefore the physician should be encouraged to order home care nurse until the wound is
sufficiently healed to prevent the risk of gangrene.
Infected diabetic ulcers require immediate surgical excision of eschar and necrotic tissue. In
addition vascular surgery may be required when the blood flow is significantly impraired or
treatment fails.

Services planned and medical equipment and supplies oderedby the physician are basis for
medicare reimbursement of wound care at home. Appropriate documentation of the patients
condition is crucial. Medicare views the following nursing skills as basic to wound care
a. Direct hands-on wound care treatment (procedural)
b. Skilled observation and assessment of the wound
c. Patient/caregiver education regarding treatment and interventions

On each visit, the home care nurse should document the treatment and procedural care and
evaluate the wound for signs of healing versus infection. As discussed previously, measure and
stage wounds weekly. Focus documentation of management on complicated procedural dressing
changes, the need for patient education, and evaluation of wound healing along with any
comorbidity status that requires the services of the skilled nurse. Wound care is covered my
medicare as long as the need for skilled care and the need for treatment are clearly and precisely
documented. As case magers, home care nursesc should be aware of other provider guidelines for
documenting wound care.
Despite everyones best efforts,healing may not always occur and the patient may require
hospitalization for more intensive therapy