Medical Diagnosis: Arterial, Diabetic, Pressure, Venous or Mixed Arterial-venous Ulcers. Nursing Diagnosis: Skin Integrity Impaired Or Tissue Integrity Impaired. 3 Light Debride 04-04-03 LB.

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Source: ConvaTec. SOLUTIONS® wound care algorithm. Skillman (NJ): ConvaTec; 2005 Dec 2. 8 p. Medical Diagnosis: Arterial, Diabetic, Pressure, Venous or Mixed Arterial-venous Ulcers Nursing Diagnosis: Skin Integrity Impaired Or Tissue Integrity Impaired 3 Light Debride 04-04-03 LB Goals of Patient Care Reduce risk factors for ulcer development and delayed healing. Prevent wound complications and promote wound healing. Wound Assessments Observed. Wound Bed/Exudate. Moist Lightly Exuding Wound Bed/Tissue Greater than 25% necrotic tissue/fibrin slough Assess for Clinical Signs and Symptoms of Infection. (Purulent Exudate and/or Elevated Temperature and/or Peripheral Induration and/or Edema.) Depth Superficial or Partial-Thickness Full-Thickness Surrounding Skin Healthy/reddened Healthy/reddened Wound Edges Healthy Healthy Undermined Goals of Wound Care Obtain clean wound bed. Maintain moist environment Maintain moist environment. prevent premature wound closure. Wound Care Plan. Cleanse. Cleanse and Debride Wound Autolytic Enzymatic. Apply enzymatic debridement agent according to package insert instructions, avoiding exposure to intact skin. Surgical: Qualified provider removes devitalized tissue with scalpel or other sharp instrument. Obtain hemostasis before dressing wound. Debride Primary Dressing Moisture Retentive Dressing Wound Hydration Moisture Retentive Dressing Wound Hydration Secondary Dressing N/A Moisture Retentive Dressing N/A Moisture Retentive Dressing Patient Care Plan Reduce risk factors for developing chronic ulcers and delayed healing, e.g.: RISK FACTORS. Arterial ulcers: Smoking, hypertension, hyperlipidemia and inactivity. Review surgical/medical management options to improve arterial circulation. Diabetic ulcers: Smoking, hypertension, obesity, hyperlipidemia and high blood glucose. Review surgical/medical management options and use appropriate off-loading techniques. Pressure ulcers: Pressure, shear, friction, nutritional deficiencies, dehydration and dry skin conditions, skin exposure to moisture or wound contamination secondary to incontinence, perspiration or other fluids, e.g. skin protection. Venous ulcers: Edema with leg elevation, ambulation and compression. If patient is not ambulatory, assure frequent ankle flexes. Review surgical/medical management options and use compression bandages if appropriate. Mixed arterial-venous ulcers: Smoking, hypertension, inactivity, hyperlipidemia. Review surgical/medical management options to improve arterial circulation and compression bandages if appropriate. All patients: Provide patient and/or caregiver teaching and support. Confirm and treat infection if needed. Assess and manage wound pain and odor if present. Expected Outcomes Wound is not infected and is healing as evidenced by a reduction in size after 2 to 4 weeks of care. No evidence of new skin breakdown. Delayed Healing Re-evaluate plan of care or address underlying etiology if ulcer has not reduced in size during 2 to 4 weeks of care All copyrights are reserved by ConvaTec.