pressure ulcer presentation3
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Pressure Ulcer Presentation
Brenda Holmes MSN, RNSeptember 7, 2007
Pressure Ulcer Presentation
Objectives Students will be able to:
identify each stage of pressure ulcers. know procedures in preventing pressure
ulcers. to follow through with the care.
Pressure Ulcer Presentation
What do you know about pressure ulcer?
Pressure Ulcer Presentation
Epidermis Dermis Subcutaneous
layer
Pressure Ulcer Presentation
Bony prominence Head, Scapula,
Vertebrae Elbows, Between
knees, Ankles, Heels
Hips, Sacral, Coccyx
Pressure Ulcer Presentation
At risk for pressure ulcer A person that remains in one position
due to inability to move self Old age Poor nutrition and lack of fluids Moisture Cardiovascular or respiratory problems Friction and shearing injuries
Pressure Ulcer Presentation
Types of pressure relieving devices Heel protectors Elbow protectors Bed cradle Footboard Air flow mattress Alternating pressure bed
Pressure Ulcer Presentation
Braden Scale New Stages of Pressure Ulcer
New as of February 2007 (Suspected) Deep Tissue Injury Stage 1 Stage II Stage III Stage IV Unstageable
Pressure Ulcer Presentation
Suspected deep tissue injury Purple or maroon
localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear
Pressure Ulcer Presentation
Stage I Nonblanchable
erythematic Treatment
Repositioning Relieving devices Heel or elbow
protectors Skin barriers
Pressure Ulcer Presentation
Stage 2 Partial thickness
loss of dermis as a shallow crater
Pink wound bed No slough (yellow) May be intact or
open blister
Pressure Ulcer Presentation
Stage III Full thickness
tissue loss Subcutaneous fat
may be visible but bone, tendon, or muscle not exposed
Slough may be present but not the depth of the tissue loss
Pressure Ulcer Presentation
Stage IV Full thickness loss
with exposed bone or tendon
Slough or eschar can be visible in some parts of the wound bed
Can include tunneling or undermining
Pressure Ulcer Presentation
Unstageable Full thickness
tissue loss with base covered by eschar (black, tan, brown, or slough (yellow, green, tan, gray, or brown)
Pressure Ulcer Presentation
Nurses’ responsibility Address issue immediately Start pressure ulcer preventative
measures as soon as MD is notified Turn patient q 2hours Inform dietician if open wound is
present Measure/describe wound on admission
and weekly
Pressure Ulcer Presentation
Nursing Assistant’s responsibility Turn resident/patient every 2 hours Provide peri-rectal care after each incontinent
episode Apply lotion or cream after each incontinent
episode (DO NOT MASSAGE) Report any skin integrity issue to primary care
nurse Assist primary care nurse as needed with
wound care (as set by each facility)
Pressure Ulcer Presentation
Treatments Heel protectors Turn q 2 hours Specialty mattress Creams, ointments, dressings, wound
vac as ordered by MD Nutritional support i.e. dietary consult,
increase protein, vitamin support (Vitamin C and Zinc)
Pressure Ulcer Presentation
Conclusion
PREVENTION
Pressure Ulcer Presentation
ReferenceNational Pressure Ulcer Advisory
Panel (2007). http://www.npuap.orgBlack, J. M. & Black, S. B. (2004).
Deep tissue injury, case study. Wounds from http://www.medscape.com/viewarticle/466563
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