ACTIVE LEARNING TEMPLATE: Diagnostic Procedure
Tabbitha Sanders
STUDENT NAME _____________________________________
Wound Healing and Management-Pressure Ulcers
PROCEDURE NAME ____________________________________________________________________ REVIEW MODULE CHAPTER ___________ATI
Description of Procedure
Relieve pressure and provide obtimal nutrition and hydration. Monitor clients regularly for skin
integrity status, risk assessment using Braden or Norton Scale.
CONSIDERATIONS
Indications
Aging skin
Nursing Interventions (pre, intra, post)
Immobility
Incontinence/excessive moisture Pre-Gather supplies, validate doctorÕs order,
Skin friction, shearing and correct patient. Take picture of intial
Obesity wound for assessment of future ulceration/
Vascular disorders infection
Inadequate nutrition/hydration Intra-Maintain moist healing environment,
Edema Apply hydrocolloid dressing, clean/debride
Sensory deÞcits wound, Administer antimicrobials if
prescribed. Post-Administer analgesics
Interpretation of Findings
Client Education
4 stages:
I-Nonblanchable erythema Keep Skin clean,dry,intact
II-Partial thickness
Shift weight every 15 minutes when sitting
III-full thickness, skin loss
IV-full thickness, tissue loss
Unstageable/unclassiÞed-full thickness skin
or tissue loss with depth unknown due to
eschar or slough obscures wound
Suspected deep tissue injury-Discoloration
Potential Complications Nursing Interventions
Deterioration to higher stage ulceration or Reposition client in bed at least every 2 hr
infection and every 1 hr in chair. Document
Systemic Infection Keep head of bed at or below 30 degrees
Ambulate patient as soon and often as
possible
Provide Supportive devices
ACTIVE LEARNING TEMPLATES THERAPEUTIC PROCEDURE A3
Tabbitha Sanders
STUDENT NAME _____________________________________
Wound Healing and Management-Pressure Ulcers
PROCEDURE NAME ____________________________________________________________________ REVIEW MODULE CHAPTER ___________ATI
Description of Procedure
Relieve pressure and provide obtimal nutrition and hydration. Monitor clients regularly for skin
integrity status, risk assessment using Braden or Norton Scale.
CONSIDERATIONS
Indications
Aging skin
Nursing Interventions (pre, intra, post)
Immobility
Incontinence/excessive moisture Pre-Gather supplies, validate doctorÕs order,
Skin friction, shearing and correct patient. Take picture of intial
Obesity wound for assessment of future ulceration/
Vascular disorders infection
Inadequate nutrition/hydration Intra-Maintain moist healing environment,
Edema Apply hydrocolloid dressing, clean/debride
Sensory deÞcits wound, Administer antimicrobials if
prescribed. Post-Administer analgesics
Interpretation of Findings
Client Education
4 stages:
I-Nonblanchable erythema Keep Skin clean,dry,intact
II-Partial thickness
Shift weight every 15 minutes when sitting
III-full thickness, skin loss
IV-full thickness, tissue loss
Unstageable/unclassiÞed-full thickness skin
or tissue loss with depth unknown due to
eschar or slough obscures wound
Suspected deep tissue injury-Discoloration
Potential Complications Nursing Interventions
Deterioration to higher stage ulceration or Reposition client in bed at least every 2 hr
infection and every 1 hr in chair. Document
Systemic Infection Keep head of bed at or below 30 degrees
Ambulate patient as soon and often as
possible
Provide Supportive devices
ACTIVE LEARNING TEMPLATES THERAPEUTIC PROCEDURE A3
