focus on pressure ulcers (relates to chapter 13, “inflammation and wound healing,” in the...

Focus onFocus onPressure UlcersPressure Ulcers

Focus onFocus onPressure UlcersPressure Ulcers

(Relates to Chapter 13, “Inflammation and Wound Healing,”

in the textbook)

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

2

Pressure UlcerPressure UlcerPressure UlcerPressure Ulcer

•A localized injury to the skin and/or underlying tissue due to pressure with or without shear/friction

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

3

IncidenceIncidenceIncidenceIncidence

•Most common sites Sacrum Heels


4

Influencing FactorsInfluencing FactorsInfluencing FactorsInfluencing Factors

•Amount of pressure (intensity)

•Length of time pressure is exerted (duration)

•Ability of tissue to tolerate externally applied pressure


5

Contributing FactorsContributing FactorsContributing FactorsContributing Factors

•Shearing force—Pressure exerted on the skin when it adheres to the bed and the skin layers slide in the direction of body movement

•Friction—Two surfaces rubbing against each other

•Excessive moisture


6

Risk FactorsRisk FactorsRisk FactorsRisk Factors

•Advanced age•Anemia•Contractures•Diabetes mellitus•Elevated body temperature


7


• Immobility• Impaired circulation• Incontinence •Low diastolic blood

pressure (<60 mm Hg)

•Mental deterioration


8


•Neurologic disorders•Obesity •Pain•Prolonged surgery•Vascular disease


9

Clinical ManifestationsClinical ManifestationsClinical ManifestationsClinical Manifestations

•Ulcers are graded or staged according to deepest level of tissue damage: Stage I (minor) to stage IV

(severe) Slough or eschar may have to

be removed for accurate staging of some ulcers.


10

Clinical Manifestations Clinical Manifestations Stage IStage I


• Intact skin with non-blanchable redness

•Possible indicators—Skin temperature, tissue consistency, pain


11



•May appear with red, blue, or purple hues in darker skin tones


12

Clinical Manifestations Clinical Manifestations Stage IIStage II

Clinical Manifestations Clinical Manifestations Stage IIStage II

•Partial-thickness loss of dermis

•Shallow open ulcer with red pink wound bed

•Presents as an intact or ruptured serum-filled blister


13

Clinical Manifestations Clinical Manifestations Stage IIIStage III


•Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia


14



•Presents as a deep crater with possible undermining of adjacent tissue

•Depth of ulcer varies by anatomic location.


15

Clinical Manifestations Clinical Manifestations Stage IVStage IV


•Full-thickness loss can extend to muscle, bone, or supporting structures. Bone, tendon, or muscle may

be visible or palpable.


16



•Undermining and tunneling may also occur.


17

Clinical Manifestations Clinical Manifestations InfectionInfection

Clinical Manifestations Clinical Manifestations InfectionInfection

•Signs Leukocytosis Fever Increased ulcer size, odor, or

drainage Necrotic tissue Pain


18

Clinical Manifestations Clinical Manifestations ComplicationsComplications

Clinical Manifestations Clinical Manifestations ComplicationsComplications

•Most common—Recurrence•Cellulitis•Chronic infection•Osteomyelitis


19

AssessmentAssessmentAssessmentAssessment

•Assess pressure ulcer risk on admission and at periodic intervals based on care setting and patient’s condition.


20

Assessment ToolsAssessment ToolsAssessment ToolsAssessment Tools

•Use risk assessment tools such as the Braden scale for systematic skin inspection.


21

Assessment of Patients With Assessment of Patients With Dark SkinDark Skin


•Look for areas of skin darker (purplish, brownish, bluish) than surrounding skin.

•Use natural or halogen light for accurate assessment (fluorescent light casts a blue color that can skew results).


22



•Assess skin temperature using your hand. An ulceration may feel warm

initially, then become cooler.


23



•Touch the skin to feel its consistency. Boggy or edematous tissue

may indicate a stage I pressure ulcer.

•Ask about pain or an itchy sensation.


24

PlanningPlanningPlanningPlanning

•Overall goals No deterioration Reduce contributing factors Not develop an infection Have healing Have no recurrence


25

Prevention – EducationPrevention – EducationPrevention – EducationPrevention – Education

•Prevention is the best treatment.

• Identify risk factors and implement prevention strategies.


26

PreventionPreventionPreventionPrevention


27

Prevention – Skin CarePrevention – Skin CarePrevention – Skin CarePrevention – Skin Care

•Remove excessive moisture.

•Avoid massage over bony prominences.

•Turn every 1 or 2 hours (with care to avoid shearing).

•Use lift sheets.


28

Prevention – Skin CarePrevention – Skin CarePrevention – Skin CarePrevention – Skin Care

•Position with pillows or elbow and heel protectors.

•Use specialty beds.•Cleanse skin if incontinence

occurs. Use pads or briefs that are

absorbent.


29

Prevention – NutritionPrevention – NutritionPrevention – NutritionPrevention – Nutrition

•Caloric intake elevated to 30 to 35 cal/kg/day or 1.25 to 1.50 g protein/kg/day Supplements, enteral, or

parenteral feedings may be necessary.


30

Treatment – Ulcer CareTreatment – Ulcer CareTreatment – Ulcer CareTreatment – Ulcer Care

•Document and describe size, stage, location, exudate, infection, pain, and tissue appearance.

•Keep ulcer bed moist.•Cleanse with nontoxic

solutions.•Debride.


31

Treatment – Ulcer CareTreatment – Ulcer CareTreatment – Ulcer CareTreatment – Ulcer Care

•Use adhesive membrane, ointment, or wound dressing.

•Verify good nutrition.•Teach self-care and signs of

breakdown.• Initiate specialty services.


32

Operative RepairOperative RepairOperative RepairOperative Repair

•Skin grafts•Skin flaps•Musculocutaneous flaps•Free flaps


34


•82-year-old woman with hypertension and limited mobility secondary to osteoarthritis and degenerative joint disease

•She lives alone.


35


•She stays in bed or sits in recliner.

•She has little ambulation or few position changes daily.

•Daughter visits once a day to help with meals and medications.


36


•Patient started on home health

• Initial assessment revealed

2 cm × 5 cm stage II ulcer to coccyx.


37


•Health aide to come 3 times a week to help

•Nurse to visit once a week to help with medication and ulcer management


38

Discussion QuestionsDiscussion QuestionsDiscussion QuestionsDiscussion Questions

1.What is the priority nursing implementation for her?

2.What interventions can help the ulcer heal?


39

Discussion QuestionsDiscussion QuestionsDiscussion QuestionsDiscussion Questions

3. What can be done to prevent future ulcers?


focus on pressure ulcers (relates to chapter 13, “inflammation and wound healing,” in the...

Documents