--Shearing: Underlying structures move perpedicular to skin above.
Assessment of Risk for pressure ulcers.
Focused skin assessment
Research Based Risk Assessment Tool:
-Braden scale* (most used)
---Numeric value for 6 risk factors related to impaired skin integrity
---Total score <18 = risk
---Numeric value for 5 risk factors
---related to impaired skin integrity
---Total score <14 = risk
Are these subjective or objective?
Nursing Diagnosis related to skin integrity
Impaired Skin Integrity Related to Pressure/Shear Injury
Pressure Ulcer Prevention
A Braden Scale total score of 18 or lower indicates the patient is at risk and that prevention planning is needed.
Start by identifying patient centered goals
--Nutrition, activity, skin care
Identify the consequences if the risk factors are not addressed
Plan preventive interventions (usually multiple interventions are needed.)
- Up in chair for meals
- Turn q 2 hrs
- Wound/nutrition consult
Outcome Identification and planning
Individualized outcomes are based on the client’s overall physical condition, the stage of the wound, and the client’s risk factors, ie don't plan or anticipate an outcome that is physically or practically impossible. If pt refuses treatment, you MUST come up with an alternative plan that still addresses pt needs. If nothing else, must at least document pt education on risks/benefits of denyting/accepting treatment.
Client teaching is an integral part of the planning process.
Nursing intervetions for pressure ulcers
Prevention: turn your pt.
Meticulous skin care and moisture control: lotions have highest water content. Creams have more oil so will be more occlusive. Oinments last longer, but have the most oil content. Will be your protective treatments. Will contain lanolyn or petrolium.