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11. Integumentary > Pressure Ulcers > Flashcards

Pressure Ulcers Flashcards

1
Q

Pressure ulcers can also be called …

A

Decubitus ulcer

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2
Q

Pressure ulcers are more commonly called …

A

Bedsores

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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.

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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!
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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
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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
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7
Q

Braden Skin Assessment Scale: scores 6 sub-scales …

A
  1. Sensory perception
  2. Moisture
  3. Activity-Mobility
  4. Nutrition
  5. Friction
  6. Shear
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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
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9
Q

Clinical Manifestations …

A

vary upon the staging of the pressure ulcer

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10
Q

Stages of Pressure Ulcers …

A
  • Suspected Deep Tissue Injury
  • Stage 1
  • Stage 2
  • Stage 3
  • Stage 4
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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
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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.
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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
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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)
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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
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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)

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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
Q

Medical & Surgical Treatment …

A
  • Debridement
  • Wound care
  • Diet
26
Q

Tx: Debridement …

A

Initial care is to remove moist, devitalized tissue

27
Q

Surgical debridement …

A

Used primarily for large amounts of nonviable tissue

28
Q

Mechanical debridement …

A
  • Wet-to-dry dressings
  • Hydrotherapy
  • Wound irrigation
  • Dextranomers
29
Q

Enzymatic & Autolytic Debridement …

A
  • Enzymes or synthetic dressings cover wound

- Self-digest devitalized tissue by action of enzymes present in would fluids

30
Q

Tx: Wound cleansing …

A
  • 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
Q

Dressings should …

A

-Protect wound
-Be biocompatible
-Hydrate
~& include: (Moistened gauze; Film (transparent); Hydrocolloid (moisture & oxygen retaining))

32
Q

NURSING PRIORITY: Ensure pressure ulcer tissue …

A
  • Stays moist

- The surrounding intact skin stays dry

33
Q

Tx: Dietary increases in …

A
  • Carbs
  • Protein
  • Vitamin C
  • Zinc
34
Q

RN Goal: To prevent/relieve pressure & stimulate circulation …

A
  • Turn Q2 hrs
  • Pressure relieving mattress
  • Memory foam/gel pads in chairs
  • Avoid trauma to skin
  • HOB elevated <30 when in bed
35
Q

RN Goal: To keep skin clean & healthy & prevent the occurrence of a pressure ulcer …

A
  • 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
Q

NURSING PRIORITY: The DO NOTs …

A
  • Massage over bony prominences

- Use donut-type devices

37
Q

NURSING PRIORITY: When side-lying position is used in bed …

A
  • Avoid positioning pt directly on the trochanter

* Use the 30º lateral inclined position

38
Q

NURSING PRIORITY: HOB should be …

A
  • At or below 30º

- or at the lowest degree of elevation

39
Q

NURSING PRIORITY: Pt edu for chair-bound pts …

A

Pts who are able, teach them to shift wt every 15 mins

40
Q

RN Goal: To promote healing of pressure ulcer …

A
  • Specialized support surfaces s/a mattresses & cushions
  • Nutritional supplements
  • Wound care dressings …
  • Keep the ulcer area dry …
41
Q

Wound Care Dressings …

A
  • Exudate absorbing
  • Debriding
  • Hydrating
  • Antimicrobial
  • Wound assisted closure-vacuum therapy
42
Q

Keeping the ulcer area dry …

A
  • 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

11. Integumentary (14 decks)

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