5 Assessment Subjective Data -Severity of ulcer pain -worse with the leg dependent-itching-duration-measures to treat the ulcer
6 Objective Data--Size-location-appearance-Color-both in a dependent and elevatedposition-Wound drainage-color and consistency-edema-Surrounding skin appearance-erythema, induration
7 Nursing Management Limb elevation -encourages return of venous blood to thegeneral circulation-increases arterial blood flow-to general circulation and lower extremities-decreased edema.Compression dressings-Unna Boot
8 -aseptic technique with dressing changes Infection Control-aseptic technique with dressing changes-monitor for signs of infection-cellulitisAntibiotics--topical (Silvadine cream)-oral or IV
9 Debridement-Removal of necrotic tissue- Mechanical-wet to dry dressings-Chemical- Enzyme (Santyl, Elase)-Surgical-used only if mechanical and chemicalmeans were ineffective-removal via scalpel of necrotic tissue
12 Pressure ulcers Causes -Pressure on the skin -collapse of capillaries (Bedsores/decubitus ulcers)Causes-Pressure on the skin-collapse of capillaries-ischemia/redness-1 hour-tissue necrosis-after 2 hours-boney prominences-
14 Shearing-Force exerted against the skin-movement or repositioning-Stretches and tears the blood vessels,-reducing blood flow-necrosis develops
15 Friction _the force of 2 surfaces moving across on another _the rubbing of skin against the sheets_removes superficial skin_increases the risk of skin breakdown
16 Moisture- incontinence urine and feces-wound drainage-perspiration
17 Staging of Pressure Ulcers Stage I- Non-blanchable erythema of intact skin
18 Stage II Pressure ulcer -Partial thickness skin loss-epidermis, dermis or both.-Ulcer is superficial-abrasion, blister or shallow crater
19 Stage III Ulcer-Full thickness skin loss-damage or necrosis to the subcutaneoustissue.-May extend down to, but not through theunderlying fascia.-Deep crater with/without undermining ofthe adjacent tissue.
20 Stage IV Ulcer-Full thickness skin loss-extensive bone destruction, tissuenecrosis, or damage to muscle, bone, orsupporting structures-Undermining and sinus tracts
25 Risk factors for pressure ulcers 1. Impaired mobility-bedbound-wheelchair bound-dependent on positioning2. Moisture-incontinent of urine and/or feces,-perspiration-wound drainage
26 3. Nutritionally compromised -underweight-obese-poor nutritional status-poor food/fluid intake-secondary to poor appetite-dysphasia-limited ability to feed themselves.4. Disease Process-diabetes-anemia-atherosclerosis,-edema5. Vitamin and Mineral Deficiencies-vitamin A, C, E, Zinc
27 Prevention of Pressure Ulcers Identify the at-risk patient-elderly-impaired mobility-poor nutritional status-altered level of consciousness
28 Prevention of Pressure Ulcers Pressure relieve-written repositioning/ turningschedule-30 degree position when side lying-pillows and foam wedges-turn sheet to reposition or lift patientin the bed-encourage patients in wheelchairs toshift their weight every 15 minutes
30 Cleansing of the skin -inspect the skin daily -mild cleanser for bathing-avoid massaging skin over a boneyprominence-moisturizer on the skin-protective barrier ointment for incontinentpatients-clean the skin at the time of incontinence.
31 Pressure relieving mattress and cushions -Egg carton mattress-Geomatt mattress-foam overlay mattress-comparatively inexpensive-Air overlay mattress-placed over the hospital bed mattress-weight redistribution-Clinitron Bed-mattress filled with small glass sand particles,-moisture flows through the mattress
32 KCI/Kin Air Bed -mattress of air-inflated pillows divided into sections-pressure can be adjusted in each of thesections according to the client’s needs-air flow form the mattress to eliminatemoisture.
33 Client education PREVENTION!!! -most important aspect to be taught to client’s and their caregivers!!1. Turning, positioning and shifting-every 2-3 hours- even during the night.2. Observe skin daily3. Diet adequate in protein, vitamins, caloriesand good fluid intake.4. Notify the health care provider for anychanges in the skin.
34 -After a pressure ulcer has appeared -Reinforce aggressive turning, positioningand pressure relief.-Home Health RN-assess the wound-instruct the client and/or caregiver-wound care-signs of healing vs. deterioration-homebound clients