Pressure Ulcers Flashcards
1
Q
Pressure ulcers can also be called …
A
Decubitus ulcer
2
Q
Pressure ulcers are more commonly called …
A
Bedsores
3
Q
Pressure ulcers are …
A
A localized injury to the skin &/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combo w/ shear &/or friction.
4
Q
ALERT: ID potential for skin breakdown …
A
- These can be & should be prevented
- ID pts @ increased r/f ulcer development
- Begin preventative care ASAP
- Do not wait for the reddened area to occur b4 preventative measures are initiated!
5
Q
Risk factors/Etiology …
A
- Immobility, shearing/friction
- Inadequate nutrition
- Incontinence (maceration/excoriation)
- Decreased sensation/pain perception
- Advancing age
- Equipment, s/a casts, restraints, traction
6
Q
Normal changes r/t to aging that increases the elderly’s risk of bedsores …
A
- Loss of lean body mass
- Decreased skin elasticity
- Decreased venous &/or arterial blood flow
7
Q
Braden Skin Assessment Scale: scores 6 sub-scales …
A
- Sensory perception
- Moisture
- Activity-Mobility
- Nutrition
- Friction
- Shear
8
Q
Braden Skin Scale scores …
A
- Total score range= 6 - 23
- Score 18 = at risk
- Score 12/< = high risk for development of a pressure ulcer
9
Q
Clinical Manifestations …
A
vary upon the staging of the pressure ulcer
10
Q
Stages of Pressure Ulcers …
A
- Suspected Deep Tissue Injury
- Stage 1
- Stage 2
- Stage 3
- Stage 4
11
Q
Pressure Ulcer: Suspected Deep Tissue Injury
A
- Purple localized area of intact skin or blood-filled blister
- Bruising
- The tissue may be painful, firm, mushy, boggy, warmer, or cooler compared w/ adjacent tissue
12
Q
Suspected Deep Tissue Injury: Description …
A
- May be difficult to detect in individuals w/ dark skin
- Evolution may include a thin blister over a dark wound bed
- -Wound may further evolve & become covered by thin eschar
- Evolution may be rapid, exposing additional layers of tissue even w/ optimal treatment.
13
Q
Pressure Ulcer- Stage 1
A
- Intact skin w/ nonblanchable redness of a localized area usually over bony prominence
- Dark skin may not have visible blanching- its color may differ from surrounding area
14
Q
Stage 1 Ulcer: Description …
A
- Area may be: painful, firm, soft, warmer, or cooler compared w/ adjacent tissue
- May be difficult to detect in pts w/ dark skin
- May indicate “at risk” pts (a heralding sign of risk)
15
Q
Pressure Ulcer- Stage 2
A
- Partial-thickness loss of dermis
- Presents as a shallow open ulcer w/ a red-pink wound bed, w/o slough
- May also present as an intact or open/ruptured serum-filled blister
16
Q
Stage 2 Ulcer: Description …
A
-Presents as a shiny or dry shallow ulcer w/o slough or bruising
(Bruising indicates a deep tissue injury)
17
Q
Stage 2 should NOT be used to describe …
A
- Skin tears
- Tape burns
- Perineal dermatitis
- Maceration or Excoriation
18
Q
Pressure Ulcer- Stage 3
A
- Full-thickness tissue loss
- SubQ fat may be visible
- Bone/tendon/muscle are not exposed
- Slough may be present
- Slough does not obscure the depth of tissue loss
- May include undermining & tunneling
19
Q
Stage 3 Ulcer: Description …
A
- Wound depth varies
- Bone/tendon is not visible or directly palpable
20
Q
Pressure Ulcer- Stage 4
A
- Full-thickness tissue loss w/ exposed bone, tendon, or muscle
- Slough or eschar may be present w/ some parts of the wound bed
- Often includes undermining & tunneling
21
Q
Stage 4 Ulcer: Description …
A
- Wound depth varies
- Can extend into muscle &/or supporting structures (fascia, tendon, joint capsule)
- Osteomyelitis is possible w/ extended ulcers
- Exposed bone/tendon is visible or directly palpable
22
Q
Wound depth in Stage 3 & 4 ulcers …
A
- Wound depth varies by anatomic location
- The bridge of the nose, ear, occiput, & malleolus do not have subQ tissue– ulcers here can be shallow
- Areas of significant adiposity can develop extremely deep ulcers
23
Q
Pressure Ulcer- Unstageable
A
-Full-thickness tissue loss in which the ulcer base is covered by slough (yellow, tan, gray, green, or brown) &/or eschar (tan, brown, or black) in the wound bed
24
Q
Unstageable Ulcer: Description …
A
- Until enough slough &/or eschar are removed to expose the base of the wound, the true depth & stage cannot be determined
- Stable (dry, adherent, intact w/o erythema or fluctuance) eschar on the heels serves as “the body’s natural (biologic) cover” & should not be removed
25
Medical & Surgical Treatment ...
- Debridement
- Wound care
- Diet
26
Tx: Debridement ...
Initial care is to remove moist, devitalized tissue
27
Surgical debridement ...
Used primarily for large amounts of nonviable tissue
28
Mechanical debridement ...
- Wet-to-dry dressings
- Hydrotherapy
- Wound irrigation
- Dextranomers
29
Enzymatic & Autolytic Debridement ...
- Enzymes or synthetic dressings cover wound
| - Self-digest devitalized tissue by action of enzymes present in would fluids
30
Tx: Wound cleansing ...
* Use NS for most cases
- Use minimal mechanical force to avoid trauma to wound bed
- Avoid using antiseptics (Dakin's solution, iodine, hydrogen peroxide)
31
Dressings should ...
-Protect wound
-Be biocompatible
-Hydrate
~& include: (Moistened gauze; Film (transparent); Hydrocolloid (moisture & oxygen retaining))
32
NURSING PRIORITY: Ensure pressure ulcer tissue ...
- Stays moist
| - The surrounding intact skin stays dry
33
Tx: Dietary increases in ...
- Carbs
- Protein
- Vitamin C
- Zinc
34
RN Goal: To prevent/relieve pressure & stimulate circulation ...
- Turn Q2 hrs
- Pressure relieving mattress
- Memory foam/gel pads in chairs
- Avoid trauma to skin
- HOB elevated <30 when in bed
35
RN Goal: To keep skin clean & healthy & prevent the occurrence of a pressure ulcer ...
- Wash skin w/ mild soap & blot completely dry w/ soft towel, esp after toileting
- Freq. inspect skin, esp bony prominences
- Use moisturizer on dry skin
- Keep pt well hydrated
- Use topical skin barrier creams/ointments/pastes
- Avoid wrinkles in sheets/clothing
36
NURSING PRIORITY: The DO NOTs ...
- Massage over bony prominences
| - Use donut-type devices
37
NURSING PRIORITY: When side-lying position is used in bed ...
- Avoid positioning pt directly on the trochanter
| * Use the 30º lateral inclined position
38
NURSING PRIORITY: HOB should be ...
- At or below 30º
| - or at the lowest degree of elevation
39
NURSING PRIORITY: Pt edu for chair-bound pts ...
Pts who are able, teach them to shift wt every 15 mins
40
RN Goal: To promote healing of pressure ulcer ...
- Specialized support surfaces s/a mattresses & cushions
- Nutritional supplements
- Wound care dressings ...
- Keep the ulcer area dry ...
41
Wound Care Dressings ...
- Exudate absorbing
- Debriding
- Hydrating
- Antimicrobial
- Wound assisted closure-vacuum therapy
42
Keeping the ulcer area dry ...
- Minimize skin exposure to moisture c/b incontinence, perspiration, or wound drainage
- Use only underpads or briefs w/ moisture absorbing material & provide quick-drying surface next to skin
- Use skin barriers
- Observe for signs of infection
