Pressure Ulcers Flashcards
Pressure Ulcers
Develop from continuous pressure that impedes capillary blood flow to skin and underlying tissue. Formerly called bedsores or decubitus ulcers.
Suspected Deep Tissue Injury
Purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage of underlying soft tissue from pressure or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared with adjacent tissue.
Stage 1 PU
Intact skin with nonblanchable redness of a localized area, usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared with adjacent tissue.
Stage 2 PU
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough. May also present as an intact or open or ruptured serum-filled blister. Presents as a shiny or dry, shallow ulcer without slough or bruising.
Stage 3 PU
Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of the ulcer varies by the location.
Stage 4 PU
Full-thickness tissue loss with exposed bone, tendon, or muscle, Slough or eschar may be present on some part of the wound bed. Often include undermining and tunneling. The depth of the ulcer varies by the location.
Unstageable PU
Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) or eschar (tan, brown, or black) in the wound bed. Until enough slough or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.
MNT for Pressure Ulcers
- Provide adequate calories
- 30-35 kcals/kg BW
- Revise and modify (liberalize)
- Provide enhanced foods and/or oral supplements between meals if needed
- NST if needed
Try to Obtain Positive Nitrogen Balance w/ Pressure Ulcers
- 1.2-1.5g of protein/kg BW
- Reassess
- Assess renal function
Monitor for Dehydration w/ Pressure Ulcers
- Wt changes
- Skin turgor
- Urine output
- Increased serum sodium
- Calculated serum osmolality
Arginine with Pressure Ulcers
Becomes depleted in critical illness. Precursor to ornithine and polyamines and is essential in wound healing. May also contribute immune stimulating functions. ASPEN Guidelines: safe in mild and moderate stress; caution in severe sepsis. Can use enteral formulas containing arginine.
Glutamine with Pressure Ulcers
Fuel source for cells with rapid turnover. No studies have been conducted on wound healing for pressure ulcer pts. Neither NPUAP or EPUAP recommend routine glutamine supplementation. Can use enteral formulas that contain glutamine.
Micronutrients Necessary for Wound Healing
- Copper
- Zinc
- Vit E
- Vit C
- Vit A
PU Documentation
- Changes in wound condition
- Changes in nutrition intervention
- Changes in lab values