pressure sores and nutrition Flashcards
factors affecting the nutritional status of patient
physical
social
emotional
metabolic
fluid balance
1500ml of water daily to survive
2-2.5l is required for normal fluid balance
influenced by temp
what to consider before feeding
how mobile
where
how
vision or hearing assistance
when are feeding tubes used
when food cannot be passed normally from the mouth to stomach
i. e.
- cancer
- trauma
- coma
- stroke
- dementia
nasogastric tube
inserted via nose into stomach.
pressure sore
a wound caused by unrelieved pressure of tissue compressed between a bony prominence and an external surface which is classified according to the extent of tissue damage
pathophys
at site of pressure sore, blood vessels collapse
occludes blood supply
results in inadequately nourished cell waste
what to do if pressure injury is discovered
- identify what stage you think
- inform senior nurse
- clearly document finding and what you did
- reassess Waterloo score, consider changing to better mattress
stage one
redness over bony prominence
may be painful, warm/cool, firm/soft
relieve pressure
moisturiser
stage two
partial thickness loss of dermis presenting shallow open wound with red wound bed
intact or open serum filled blister
allevyn
biatain
comfeel
stage three
full thickness tissue loss. fat may be visible but bone or tendon are not exposed. slough may be present
intrasite gel
alginate
aquacel/exufibre
allvyen
stage four
full thickness tissue loss with exposed bone tendon or muscle
Negative pressure wound therapy
management of pressure sores
- reduction of pressure
- management of exudate
- prevention of contamination
- creation of moist wound environment
- minimise frequency of dressing change
secura z10 and z30
protect skin from moisture
do not apply to pressure areas
IAD
affected skin is red
skin damage pattern is diverse
depth of IAD related skin damage usually is partial thickness without necrotic tissue
