Integumentary Part 3 Flashcards
Pressure Ulcers
Caused by unrelieved pressure resulting in damage to underlying tissue
Pressure Ulcers usually occur over
bony prominences
Sacrum, heels, ischial tuberosities, and greater trochanters, elbows, scapula
Pressure Ulcers Risk Factors
- Decreased sensation or mobility (Bed- and chair-bound clients)
- Incontinence
- Obesity
- Nutritional factors
- Pressure, shear, friction, and moisture
- Chronic disease accompanied by anemia, edema, renal failure, or sepsis
- Altered level of consciousness
Stage 1 Pressure Ulcer
Non blanchable erythema
The heralding lesion of skin ulceration
Stage 2 Pressure Ulcer
Partial thickness skin loss involving epidermis or dermis or both
Ulceration is superficial and appears clinically as an abrasion, blister or shallow crater
Stage 3 Pressure Ulcer
Full-thickness skin loss
Fat is visible
Slough and/or eschar may be visible
Fascia, muscle, tendon, ligament, cartilage and/or bone are NOT exposed
Stage 4 Pressure Ulcer
Full thickness skin and tissue loss
Exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer
Slough and/or eschar may be visible
Unstageable Pressure Ulcer
Full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed
Until enough slough and/or eschar is removed, the true depth, and therefore stage, cannot be determined
Deep Tissue Pressure Injury
Intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister
- Continuous pressure of soft tissues between bony prominences
Compresses capillaries & occludes blood flow
If the pressure is relieved —>
reactive hyperemia
If the pressure is not relieved —>
form necrotic tissue
Superficial sores
Common on the
sacrum (due to shearing or friction forces)
Deep sores Develop closer to the
bone as a result of tissue distortion and vascular occlusion, e.g., over heels, trochanters, and ischii
Deep lesions often go undetected until they
penetrate the skin
Successful healing requires
- Relief of pressure
- Absence of infection
Wet-to-dry dressing -
no longer acceptable
Therapeutic interventions may include
pulsed lavage with suction (PLWS), electrical stimulation, ultrasound, and debridement
Negative Prognostic factors
- Infection
- Poor nutrition or blood supply
- Failure to eliminate pressure
- Medical complications
- Incontinence
Risk Assessment
All clients at risk
A systematic skin inspection at least daily (especially) bony prominences
In bed, reposition
at least every 2 hours in bed
Positioning devices
Pillows or foam wedges, e.g., knees and ankles
- Prone, Supine, Side-lying position
- Avoid positioning directly on the
greater trochanters, heels, bony prominences
- Preventing Friction
- Use lifting devices
- A trapeze bar
- A mechanical lift or a slide board
- Linen can be used to move persons in bed who cannot assist during position changes
