The flashcards below were created by user
foxyt14
on FreezingBlue Flashcards.
-
Describe the pathophysiology of pressure ulcers:
Excessive or prolonged pressure from body weight leading to ischemia and necrosis from impaired blood flow to an area
-
What causes pressure ulcers?
- shearing forces
- moisture
- poor hygiene
- inadequate nutrition
- increased body heat in a localized area
- anemia
- immobility
-
How do you prevent pressure ulcers?
- Braden scale is done upon admission. It evaluates:
- nutrition, physical and mental condition, activity and mobility on a scale.
Low score = high risk
-
Subjective data you will receive during assessment of a pressure ulcer:
- may be unaware of the ulcer because they may not have pain sensation cuz circulation to nerve endings is impaired.
- This happens if they have chronic illness that is related to the ulcer..diabetes
-
Objective data I will see when assessing a pressure ulcer:
- 4 S's
- Site
- Shape/Size
- Stage
- Sepsis
Is there exudate present-if yes, describe type, color and amount of saturation
-
How do you care for a person with a pressure ulcer?
- Turn q 2h
- ROM exercises
- Pillows UNDER calves
- PT
- Nutrition
- I&O
- skin care
- right gauze, dressing, gels
- Debride and pack
- **Reassess every day, monitor labs and document if its getting better or worse
-
Who is at risk for pressure ulcers?
- Paralyzed
- Bed bound
- Semi Conscious or unconscious
- Malnourished
- Obese
- Over 85 and incontinent
- Decreased mobility
- Vascular/Circulatory Impairment
-
Bony prominences to watch for pressure ulcers....
- heels
- sacrum
- elbows
- trochanter
- poster and anterior iliac spine
-
Describe Stage I pressure ulcer
Red that doesnt go away after 30 minutes
No skin breakdown
-
Describe Stage II pressure ulcer
- Partial thickness seen by:
- crack, abrasion, blister
- Superficial circulation and tissue damage
-
Describe Stage III pressure ulcer:
- Full thickness
- Ulceration of all subcutaneous skin layers.
It goes in to the fatty tissues, but not supporting structures
-
Describe Stage IV pressure ulcer:
Full thickness
- Deep ulceration thru muscle tissue to bone or supporting structures. (Tendons, bones)
- Tissue necrosis and wound drainage is present
-
Maceration
moist skin, think of a wet band aid
-
Shearing
1 layer of tissue is pulled over another layer of tissue, scraping it.
-
Tunneling
deep hidden places in a sore that you cant see.
Only seen in stages III and IV
-
Undermining
lip of infected and necrotic tissue that can be felt around a wound when a cotton tip is placed in to the edges of a wound
-
Describe the best way to care for a Stage I pressure ulcer
- Doctors order
- Spray granulex q 8h to improve circulation to the area, leave open with non adhering dressing
- OR
- cover wound with foam, tape all edges with paper tape and change 3-7 days later
- OR
- cover wound with opsite, and change the dressing when it peels away from the skin
-
Describe the best way to care for a Stage II pressure ulcer
- Irrigate or flush with NORMAL SALINE
- cover with Granulex spray, foam dressing or wound gel
- OR
- cover wound with Duoderm or foam dressing
-
Describe the best way to care for Stage III and IV pressure ulcers
- DR. ORDER needed to specificy substances to clean or pack. Needs to be cleaned really well (if using NORMAL SALINE dont need doctors ok) before staging or repacking
- Debridement if has eschar or slough, cover, pack and keep it moist to absorb excess exudate
-
How do you document healing of a pressure ulcer....let's say it is a stage IV.
- It is now a "healing Stage IV"....it never gets termed a III, II or I.
- Use READS and use a clock to describe length and width
-
Goals for care of a pressure ulcers
- within 1 week the pressure ulcer will show signs of healing AEB:
- decrease in size and depth
- lack redness, drainage
- show no signs of infection
- will see signs of formation of healthy skin over the site
-
Goals for Stage I and II pressure ulcer management
No further redness or signs of skin or tissue breakdown
-
Goals for Stage III and IV pressure ulcer management
pt will show no further evidence of increase in skin/tissue breakdown
-
Identify vitamins and minerals which play a big role in wound healing and discuss food sources of these....
-
Describe differences in the manifestation of pressure ulcers in dark skinned individuals
Problems: they dont show redness or blach over bony prominences. Take a pic to show differences in colors better
- Try to:
- look for changes compared to surrounding skin
- Know ulcer site may look darker than surrounding skin
- site may look taut, shiny from swelling
- will be warm to the touch, but will feel cool as circulation decreases
- assess for signs of pain or discomfort at the site
-
State an appropriate nursing diagnosis for a patient with Stage I or II pressure ulcer
Imparied SKIN integrity R/T immobility, poor nutritional status, impaired circulation, AEB 2 cm, round, non disappearing reddened area under the heel
-
State an appropriate nursing diagnosis for a patient with a Stage III or IV pressure ulcer
Impaired TISSUE integrity R/T immobility, incontinence, poor nutritional status, AEB Stage III pressure ulcer over the rt. sacral area
|
|