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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
- poor hygiene
- inadequate nutrition
- increased body heat in a localized area
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
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
- 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?
- Bed bound
- Semi Conscious or unconscious
- Over 85 and incontinent
- Decreased mobility
- Vascular/Circulatory Impairment
Bony prominences to watch for pressure ulcers....
- 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:
- Deep ulceration thru muscle tissue to bone or supporting structures. (Tendons, bones)
- Tissue necrosis and wound drainage is present
moist skin, think of a wet band aid
1 layer of tissue is pulled over another layer of tissue, scraping it.
deep hidden places in a sore that you cant see.
Only seen in stages III and IV
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
- cover wound with foam, tape all edges with paper tape and change 3-7 days later
- 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
- 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