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Chapter 34 Pressure Ulcers Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

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Presentation on theme: "Chapter 34 Pressure Ulcers Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved."— Presentation transcript:

1 Chapter 34 Pressure Ulcers Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

2 Pressure Ulcers Definitions: – Bony prominence —area where the bone sticks out or projects from the flat surface of the body – Shear—when layers of the skin rub against each other, or when the skin remains in place and underlying tissues move and stretch and tear underlying capillaries and blood vessels – Friction—the rubbing of one surface against another Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 2

3 Sites Pressure ulcers usually occur over bony prominences (pressure points). – These areas bear the weight of the body in a certain position. According to the CMS, the sacrum is the most common site for a pressure ulcer. Other sites include: – Heels – Ears – Areas where medical equipment is attached to skin – Areas where skin has contact with skin Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 3

4 Common Equipment Sites: Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 4

5 Persons at Risk Who are our persons at risk for pressure ulcers?: – Are bedfast or chairfast – Need some or total help in moving – Are agitated or have involuntary muscle movements – Have urinary or fecal incontinence – Are exposed to moisture – Have poor nutrition – Have poor fluid balance – Have lowered mental awareness – Have problems sensing pain or pressure – Have circulatory problems – Are obese or very thin – Have a healed pressure ulcer Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 5

6 Pressure Ulcer Stages Skin color change remaining after pressure is relieved. – Persons with light skin—a reddened bony area – Persons with dark skin—skin color differs from surrounding areas The skin may feel warm or cool. The person may complain of pain, burning, tingling, or itching in the area. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 6

7 Pressure Ulcer Stages Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 7

8 Stage 1 Intact skin with redness over a bony prominence. Color does not return to normal when skin is relieved of pressure Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 8

9 Stage 2 Partial-thickness skin loss-appears as blister or shallow ulcer Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 9

10 Stage 3 Full thickness tissue loss-skin is gone, subcutaneous fat may be exposed, slough (light colored, soft, moist dead tissue may be present) Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 10

11 Stage 4 Full-thickness loss with muscle, tendon, and bone exposure. Slough and eschar may be present. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 11

12 Unstageable Full thickness tissue loss with ulcer covered by slough and or eschar making it unable to stage. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 12

13 Tunneling Wound continues beneath the skin-Makes staging difficult to determine Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 13

14 Prevention and Treatment Good nursing care, cleanliness, and skin care are essential. The Joint Commission (TJC) and the CMS require pressure ulcer prevention programs. Prevention includes: – Identifying persons at risk-most facilities use a Braden scale-we will do this later Some agencies use symbols or colored stickers as pressure ulcer alerts. – Implementing prevention measures for those at risk Support surfaces are used to relieve or reduce pressure. – Following the person’s care plan Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 14

15 What are some basic prevention methods? Bed cradle Heel and elbow protectors Heel and foot elevators Gel mats Eggcrates Special mattress Positioning devices Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 15

16 Prevention Methods Egg mattress Bedcradle Elbow and heel protectors Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 16

17 Complications Infection is the most common complication. – Colonized—the presence of bacteria on the wound surface or in wound tissue. The person does not have signs and symptoms of an infection. – Osteomyelitis—inflammation of the bone and bone marrow. This is a risk if the pressure ulcer is over a bony prominence. The person has severe pain. Pain management is important. – Pain may affect movement and activity. – Immobility is a risk factor for pressure ulcers. It may delay healing of an existing pressure ulcer. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 17

18 Reporting and Recording A complete head to toe skin assessment should be done on any new resident or any resident returning from a hospital stay Report and record any signs of skin breakdown or pressure ulcers at once. Be specific as possible and describe size as compared to standard object (quarter, dime, etc.) Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 18

19 Pressure Ulcer Descriptions Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 19

20 Braden Risk Assessment Used to evaluate which patients might be at risk for skin breakdown Scored from 0 (high risk) to 23 (low risk) Break up into groups to score your patients The Braden Scale assessment score scale: – Very High Risk: Total Score 9 or less – High Risk: Total Score – Moderate Risk: Total Score – Mild Risk: Total Score – No Risk: Total Score Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Slide 20


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