Presentation is loading. Please wait.

Presentation is loading. Please wait.

Integumentary System, PN 124.  Causes  - chronic deep vein insufficiency  - delay of venous blood returning to the  central circulation  -severe.

Similar presentations


Presentation on theme: "Integumentary System, PN 124.  Causes  - chronic deep vein insufficiency  - delay of venous blood returning to the  central circulation  -severe."— Presentation transcript:

1 Integumentary System, PN 124

2  Causes  - chronic deep vein insufficiency  - delay of venous blood returning to the  central circulation  -severe varicose veins, burns, trauma,  sickle cell anemia, diabetes, neurogenic  disorders and heredity

3  -Dry/rough looking skin  -Hard to the touch  -Loss of body hair  -Ulcers begin as small, tender, inflamed  -Edema around the ulcer  -Occasional purulent drainage  -Slow to heal

4

5  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 elevated position  -Wound drainage -color and consistency  -edema  -Surrounding skin appearance -erythema, induration

7  Limb elevation -encourages return of venous blood to the general circulation -increases arterial blood flow -to general circulation and lower extremities -decreased edema.  Compression dressings -Unna Boot

8  Infection Control  -aseptic technique with dressing changes -monitor for signs of infection -cellulitis  Antibiotics- -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 chemical  means were ineffective  -removal via scalpel of necrotic tissue

10

11  Dressings  -Compression  -Unna boot, Ace bandages, TED socks  Pain Management  -Elevate legs, analgesics, topical  anesthetics  Nutrition  -Protein, Vitamin A, Vitamin c, Zinc

12 (Bedsores/decubitus ulcers) Causes -Pressure on the skin -collapse of capillaries -ischemia/redness-1 hour -tissue necrosis-after 2 hours -boney prominences -

13

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  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 subcutaneous tissue.  -May extend down to, but not through the  underlying fascia.  -Deep crater with/without undermining of the adjacent tissue.

20  Stage IV Ulcer  -Full thickness skin loss -extensive bone destruction, tissue necrosis, or damage to muscle, bone, or supporting structures -Undermining and sinus tracts

21  Surrounding skin  -intact edges  -erosion  -maceration  -erythema  -edema

22  Braden Assessment Tool  Norton Pressure Ulcer Scale

23

24  Norton Assessment Tool

25  Risk factors for pressure ulcers  1. Impaired mobility  -bedbound  -wheelchair bound  -dependent on positioning  2. 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, -edema 5. Vitamin and Mineral Deficiencies -vitamin A, C, E, Zinc

27  Identify the at-risk patient  -elderly  -impaired mobility  -poor nutritional status -altered level of consciousness

28  Pressure relieve  -written repositioning/ turning schedule  -30 degree position when side lying  -pillows and foam wedges  -turn sheet to reposition or lift patient in the bed  -encourage patients in wheelchairs to shift their weight every 15 minutes

29

30  Cleansing of the skin  -inspect the skin daily  -mild cleanser for bathing  -avoid massaging skin over a boney  prominence  -moisturizer on the skin  -protective barrier ointment for incontinent  patients  -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 the  sections according to the client’s needs  -air flow form the mattress to eliminate  moisture.

33  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 daily  3. Diet adequate in protein, vitamins, calories and good fluid intake.  4. Notify the health care provider for any changes in the skin.

34  -After a pressure ulcer has appeared  -Reinforce aggressive turning, positioning and pressure relief.  -Home Health RN  -assess the wound  -instruct the client and/or caregiver -wound care -signs of healing vs. deterioration -homebound clients


Download ppt "Integumentary System, PN 124.  Causes  - chronic deep vein insufficiency  - delay of venous blood returning to the  central circulation  -severe."

Similar presentations


Ads by Google