Pressure Ulcers Flashcards
Skin
Largest organ Covers 2 square meters in adult Acidic protective coating PH 4.2-5.6 Ranges from 1/8-1/25in in thickness Receives 1/3 of body's circulating blood volume
Tissue Integrity
State of structurally intact and physiologically functioning epithelial tissues such as the integument (including skin and subcutaneous tissues) and mucous membranes
Skin Functions
Sensation Vitamin D synthesis Thermo-regulation via circulation and sweating Protects Skin immune system
Skin layers
Dermal
Epidermis
Dermis
Epidermis layers
Stratum corneum Stratum lucidem Stratum granulosem Stratum spinosum Melanocyte Stratum basale
Dermis layers
Papillae
Papillary region
Reticular region
Physiologic Processes
Protection
Absorption
Secretion
Excretion
Epithelial cells cover all internal and external body surfaces
Factors that alter skin
Age Sun Hydration Soaps Nutrition Medications
Diseases that impact skin
Diabetes Auto immune disorders Cancer Vascular disorders Psychiatric
Pressure Ulcer
Pressure sore
Decubitus ulcer
Bed sore
Pathogenesis
Pressure intensity
- tissue ischemia
- blanching
Pressure duration
Tissue tolerance
Pressure Ulcer Risk Factors
Impaired sensory perception Alterations in level of consciousness Impaired mobility Shear Friction Moisture
Pressure ulcer prevention
Pressure relief devices Skin care Incontinence care Activity Nutrition Prevention
Eschar
Black tissue, tissue necrosis
Stage 1 PU
Intact skin with non-blanchable redness
Changes in color, warmth, sensation, tissue consistency (no open areas)
Stage 2 PU
Partial thickness skin loss involving epidermis, dermis, or both
Superficial, loss of epidermis or dermis (abrasion, blister, shallow crater)
Stage 3 PU
Full thickness tissue loss with visible fat
Damage or necrosis of subQ fat layer that extends to fascia
Deep crater, may undermine
Stage 4 PU
Full thickness tissue loss with exposed bone, muscle, or tendon
Extensive destruction, damaged bone, cartilage, muscle, tendon or joint capsules, tissue necrosis may be present
Braden scale
Sensory perception Moisture Activity Mobility Nutrition Friction/Shear
Suspected deep tissue injury
Dark purple, non blanchable
Unstageable
Eschar, unable to determine depth
Specialty mattress indicators
- Patient is paraplegic or quadriplegic
- Skin breakdown on 2+ turning surfaces
- Stage 3 or 4 PU on bony prominence
- Altered level of consciousness/mentation/or inability to recognize painful stimuli or need to reposition self frequently
- NPO>72hrs
- poor nutrition
- albumin 10min in chair BID and NWB
NP:ASSESSMENT
A-location and extent of tissue damage-measure
Pain, edema, redness, drainage, wound edges approximated
-inspect for bleeding, foreign bodies, associated injuries
-determine status of tetanus immunization
NP:DIAGNOSIS
- risk for impaired skin integrity
- impaired skin integrity
- impaired tissue integrity
- risk of infection
- pain
NP:PLAN
- Maintain skin integrity
- Demonstrate progressive wound healing
- Patient education
NP: IMPLEMENTATION
- moist wound healing
- nutrition and fluid
- preventing infection
- positioning
NP: EVALUATION
- Skin and tissue integrity maintained
- Wound decreases in size
- Demonstrates understanding of preventative care
