Hyponatremia < 135mEq/L

Hypernatremia > 145mEq/L

Neurologic Sx: Confusion, Seizures, Coma

Hypokalemia < 3.5mEq/L

Hyperkalemia > 5.0mEq/L

Important for: Skeletal, cardiac, smooth muscle; nerve conduction; multiple organ systems

Cardiac Sx: EKG changes

Hypocalcemia < 9mg/dL

Hypercalcemia > 10.5mg/dL

Important for: bone formation, blood, coagulation, neuromuscular activity, release of hormones and neurotransmitters

Manifestations/Sx: cardiac arrythmias, altered mental status, changes in reflexes and muscle activity

Hypoglycemia < 70mg/dL

Manifestations: rapid onset HA, shaky, dizzy, anxious, weak, confused, palpitations, increased HR

Hyperglycemia > 250mg/dL

Manifestations: gradual onset thirst, freq urination, drowsy, arrythmias, confusion, fruity breath

Leukopenia < 5000cells/mm3

Leukocytosis > 10000cells/mm3

Produced in bone marrow, indicate presence of infection, allergens, inflammation

Thrombocytopenia < 150000

Thrombocytosis > 400000

Platelets produced in bone marrow and initiate clotting sequence

< 20000 increased bleeding risk

<10000 No exercise

10000 - 20000 Therex/Bike without resistance

> 20000 Therex/Bike with/without resistance

Men: 14 to 18 g/dL

Women: 12 to 16 g/dL

Concentration of O2 carrying component in 100mL of blood

< 8 Light ROM, isometrics

< 8-10 ADLS, light aerobics and wts.

> 8 Amb. and self care as tolerated, resistance exercises

Hematocrit Lab Values

Men: 42 to 52%

Women: 37 to 47%

% of whole blood which is RBC

< 25% Light ROM, isometrics

< 25-35% ADLS, light aerobics and wts.

> 25% Amb., self care as tolerated, resistance exercises

PTT: Normal 60-70s; anticoagulation 2-2.5x ref range

aPTT: Normal 30-40s

PT: Normal 11-12.5s; anticoagulation 1.5-2x ref range

INR: Normal 1-2; anticoagulation 2-3; mech heart valves 2.5-3.5

Warfarin ==> INR

Heparin ==> aPTT

LMWH ==> None.

Anterior: No hip extension, no hip external rotation

Posterolateral: No hip flexion > 90 degrees, no internal rotation, no hip add past midline

Inflammatory: injury to several days, vascular and cellular responses

Proliferation: 48 hrs to weeks, angiogenesis, granulation, wound contraction, epithelialization

Remodeling/Maturation: up to 2 years.

Antimicrobial - destroy unicellular microorganisms, topically or systematically

Antibacterial / Antifungal

Gentamycin Gram-, Sulfamyalon Broad spectrum, Bactroban Gram+/-, Nystatin Yeast infection

Silver sulfadiazine Broad spectrum

Antiseptic

Acetic Acid Pseudomonas, Hydrogen peroxide protect from sunlight, Dakin's bleach

Stage I - intact skin with localized blanchable redness

Stage II - partial thickness injury; shallow ulcer, blister, abrasion, clean wound bed

Stage III - full thickness wound; skin loss down to but not through fascia; crater with/without undermining, tunneling

Stage IV - full thickness with exposed bone, tendon, muscle; with/without undermining or tunneling

Suspected Deep Tissue Injury - localized discolored intact skin or blood-filled blister

Unstageable - likely full thickness, base obscured by NVT

Wagner Classification

Grade 0 - no ulcer but high risk foot, may have preulcerative lesions, healed ulcers, presence of deformity

Grade 1 - superficial ulcer w/o SQ involvement

Grade 2 - penetration through SQ tissue, may expose bone, tendon, ligament, joint capsule

Grade 3 - deep ulcer with osteitis, osteomyelitis, abscess

Grade 4 - localized gangrene

Grade 5 - gangrene of foot requires disarticulation

Wound Debridement

Purpose/Contraindications

Purpose: Decrease bacterial concentration and risk of infection; Increase effectiveness of topical antimicrobials; Improve bacteriacidal activity of WBCs

Shorten the inflammatory phase; Decrease energy required for wound healing; Eliminate physical barrier

Decrease wound odor

Contraindications: Healthy granulation tissue, stable eschar, non-viable deeper structures, impaired vascular status, gangrene, osteomyelitis, electrical burns, stage III/IV pressure ulcers

The use of forceps, scissors, and scalpel to selectively remove tissue, foreign material, debris

Indications:

necrotic tissue, callus, advancing cellulitis or sepsis, chronic wounds

Contraindications:

stable eschar, dry gangrene, impaired arterial flow and clotting, unidentified structures, poor health status, hypergranulation

Most conservative, less painful and less invasive method of debridement

Indications:

Any wound with manageable amounts of necrotic tissue, unable to tolerate other forms of debridement

Contraindications:

Presence of infection or deep cavities

Surgical or sharp contraindicated

Dry gangrene

Topical exogenous enzymes promote selective emulsification of NVT

Indications:

Infected or uninfected wounds with NVT, Cannot tolerate other forms of debridement, With antimicrobials and sharps.

Contraindications: 

Clean granulating wounds, exposed deep structures, sharp/surgical appropriate, concurrent use of acidic solutions, facial wounds, heavy draining wounds, > 2 weeks of use.

Non Selective - Mechanical

Wet to Dry

Indications:

100% NVT or risk of harming healthy tissue does not exceed the benefit or removing NVT; great for loose-moist NVT

Contraindications:

Granulation tissue or exposed deep structures, concurrent anticoagulant therapy

Non-Selective - Mechanical

Irrigation

Use saline/H20 and applied with minimal force to remove loosely adherent contaminants

Indications: 

All wounds, only intervention indicated for granulating wounds

Contraindications:

active, profuse bleeding

Non-Selective - Mechanical

Whirlpool

Immersion of involved body part into tank filled with H2O and possible antimicrobial additives

Indications:

Malodorous wounds, infected wounds, nondraining wounds, loosen/soften adherent NVT, thick eschar or exudate, presence of foreign material

Contraindication:

Clean granulating wound, compromised cardiopulmonary and renal functions, active bleeding, impaired sensation or cognition, seizures, incontinence, dry gangrene

Non-Selective - Mechanical

Pulsatile Lavage

Form of irrigation with pressurized stream of solution

Indications: 

Most wound etiologies requiring thorough irrigation/debridement, tunneling/undermining, soften and remove necrotic tissue/exudate.

Contraindications: 

Exposed structures or cavities

Recent surgical procedures, active bleeding, latex allergy, insensitivity, deep tunning wounds, and anticoagulant usage

Highly permeable and non-occlusive, adherent to wounds

Indications:

Infected/non-infected wounds of any shape, size or etiology, alone or in combination, when packing is required, economical choice for frequent dressing changes

Contraindications/Precautions:

Can cause trauma to wound bed with removal

Watch for residual fibers left in the wound

Do not wrap in tourniquet fashion.

Gauze with hydrogel, petroleum, saline, bismuth or zinc, non-adherent and possible more occlusive

Indications:

Contact later in granulating or NV wounds, in conjunction with topical agents, exposed structures infections, burns, epithelializing wounds, wounds that easily bleed

Precautions/Contra:

Bismuth or iodine are cytotoxic

Thin, flexible sheet of transparent polyurethane with adhesive backing, little or no absorption, imperm to bacteria and water, perm to vapor, O2 and CO2

Indications:

Superficial and partial thickness wounds, secondary dressing over topical agents, cover and protect IV sites, areas of friction

Contra/Precautions:

Utilize skin protectant

Monitor edge seal

Infected wounds

Copious exudate

Permeable to gas and water, not effective as bacterial barrier, require secondary dressing

Indications:

Dry to moderately draining wounds, tough eschar, exposed structures, most wound types, burns, pressure ulcers, blisters, abrasions, softened eschar

Contra/Pre:

Heavily draining wounds

Infected wounds

Utilize skin protectant to periwound

Semipermeable Foams

Soft polyurethane foam wth waterproof backing, no adherence to wound bed, may need secondary dressing

Indications:

Nearly all wounds with min-heavy exudate

Alone or in combination - can be secondary dressing over gel/ointment

Contra/Pre:

Dry eschar-covered wounds

Utilize skin protectants on periwound

Change daily on infected wounds

Gel forming hydrophilic polymers in suspension on a film/foam backing, imperm to water, O2, bacteria, absorb exudate slowly

Indications:

Safe use in small cavities

Granular and necrotic wounds

Partial and full thickness wounds

Moderately draining wounds.

Contra/Pre:

Infected wounds, dry or heavily draining wounds

Exposed structures, watch for development of hypergranulation, fragile periwound

Calcium or calcium/sodium salts composed of acids from seaweeds, maintain moist env, trap bacteria, absorbe up to 20x

Highly permeable, non-occlusive, require secondary dressing

Indications:

partial and full thickness wounds, infected wounds, moderate to high drainage, bleeding wounds, granular and necrotic wounds

Contra/Pre:

Minimal to no drainage, thick black eschar, full thickness burns, over exposed structures, utilize skin sealant to protect periwound, change dressing on wound daily.

1st Degree - epidermal injury

2nd Degree - Superficial dermal injury or deep dermal injury

3rd and 4th Degree - full thickness to SQ fat, muscle and possible bone

Zones

Coagulation - central area; greatest or irreversible damange, NV eschar

Stasis - marginally viable, easily damage w/o fluid and adequate woundcare

Zone of hyperemia - least damage, most rapid to heal unless additional tissue injury occur

Most accurate predictor of TBSA

Adjusted for age/growth

Greater number of body divisions

Determines fluids required