Pressure Ulcers

No body system is immune from effects of immobility. Metabolic changes, respiratory, cardio, msculoskeletal

Respiratory system and checked every 2 hrs

Atelectasis and hypostatic pnemonia

emotional and behavioral responses, sensory alterations and changes in coping. Changes include hostility, giddiness, fear and anxiety. Creates sleep-wake alterations, client may become depressed b/c of changes in role and self-concept

taking immediate action to relieve specific issues such as in an emergent situation

medicare, medicaid, maximize functions and abilities, optimum level of health, independent manage ADL's, social and emotional participation. Collaborative working relationship.

Early ROM assessment is best to do before client becomes Immobile

must assess every 2 hours and every 30 minutes for the 1st 2 hours, flowsheet must be completed, document why and have 2 finger allowance. Using restraints is an independent nursing judgement

impaired skin integrity related to unrelieved prolonged pressure. Localized areas of necrotic tissue, tissue compressed b/t bony prominence and external surface

decreased mobility, decreased sensory, fecal and urine incontinence, poor nutrition, interference with cell metabolism obliterates blood flow, anything that stops blood flow and causes tissue ischemia (lack of blood supply)

High protein, high caloric to rebuild tissue b/c when immobile amnio acids are coming out of muscle, this type of diet helps rebuild

• Pressure intensity
• tissue intolerance
• duration

capillary closing pressure as the minimal amount of pressure required to collapse a capillary. If the pressure applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for prolonged period of time tissue ischemia can occur

lack of oxygen leads to tissue death (tissue is white)

• (redness) once blood flow continues and oxygen returns to pressure area. Visible local vasodialation occurs.
• if you put your finger over red spot it blanches white then red comes back (if red does not come back and blanching stays then there is deep tissue loss)

Use anthropometric measurements (height, weight, skinfold thickness) to evaluate msucle atrophy

if it appears darker than surrounding skin, has a purplish/bluish huse, if there is initial warmth when compared with surrounding skin, later coolness as tissue is devitalized

excessive vasodilation and induration in response to pressure. The area does not blanch when you apply pressure deep tissue damage is probable (redness just stays when pressure applied)

• Force exerted parallel to skin resulting from both gravity pushing down on the body and resistance b/c the client and a surface (when person slides down in bed)
• underlying tissue capillaries are stretched and angulated by shear force
• tissue damage occurs deep in tissues, causing undermining of dermis

• the force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens
• affect epidermis (top layer)
• occurs when lifting client up in bed

• the ability of tissue to endure pressure
• depends on the integrity of the tissue and the supporting structures

intact skin with nonblanchable redness of a localized area usually over a bony prominance

partial-thickness skin loss involving epidermins, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister or a shallow crater

Full-thickness tissue loss. Sub Q fat may be visible, but bone, tendon, or muslce are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling

Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound. Often includes undermining and tunneling.

greater trochanter, sacrum, ishial tuberosity, heels

wound vacs, wet to dry dressing, nutrition

• nutrition
• tissue perfusion
• infection
• age
• psycholocial impact of wounds

use braden scale

red moist tissue composed of new blood vessels which indicate progression toward healing

soft yellow or white tissue (stringy substance attached to wound bed) need to remove this before would can heal

black or brown necrotic tissue, also need to remove before it can heal

partial or total separation of wound layers

protrusion of visceral organs through a wound opening