Pressure Ulcers and Wounds

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Author:
MLBuonarosa
ID:
104643
Filename:
Pressure Ulcers and Wounds
Updated:
2011-09-27 11:44:35
Tags:
pressure ulcers
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Description:
Pressure Ulcers and Wounds
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  1. Orthostatic Hypotension
    • decreased ability to
    • equalize blood supply when moving lying to standing position.
    • Caused by decreased circulating fluid volume
    • and pooling of blood in lower extremities.
    • Results in decreased venous return; decreased cardiac output and
    • decreased BP
  2. Virchow’s triad
    • Changes or injury to vessel walls+Hypercoagulabilityof the blood + venus stasis
    • can lead to DVTs
  3. Risk factors for
    DVT: CHAMPIONS
    • Critically ill
    • Hypercoagubility; history of DVT
    • Age; air travel
    • Malignancy
    • Pregnancy
    • Immobilizing illness
    • Orthopedic procedure
    • Not known (???)

    • Superficial
    • thrombophlebitis
  4. Pressure ulcer
    Localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear
  5. Pressure ulcer: Stage I
    Intact skin with nonblanchable redness of a localized area usually over a bony prominence
  6. Pressure ulcer: Stage II
    • Partial thickness loss of dermis
    • Shallow open ulcer
    • Red, pink wound bed NO SLOUGH
    • May also be intact or
    • open/ruptured serum-filled blister
  7. Pressure ulcer: Stage III
    • Full thickness tissue loss
    • Sub Q tissue may be visible, but not bone and muscle
    • Slough may be present but can still see depth of tissue loss
    • May include undermining or tunneling
  8. Pressure ulcer: Stage IV
    • Full thickness tissue loss with
    • Exposed bone, muscle or tendons
    • Slough or eschar may be present in part of wound
    • Often includes tunneling and undermining
  9. Pressure ulcer: Unstageable
    • Full thickness tissue loss
    • Base of ulcer wound bed covered in slough and/or eschar

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