Care of Patients with Pressure Ulcers Chapter 43 Care of Patients with Pressure Ulcers

Theory Objectives Describe the etiology of dermatitis. Plan psychosocial interventions for the patient who has psoriasis. Compare the treatment of fungal skin or nail disorders to the treatment of bacterial skin disorders. List the main nursing care points for patients with herpes virus infections. deWit Medical Surgical Nursing 8/19/2013

Theory Objectives (cont.) Discuss the important points of caring for an immobile patient to prevent pressure ulcers. Prepare care plan interventions for each stage of a pressure ulcer. deWit Medical Surgical Nursing 8/19/2013

Pressure Ulcers Risk factors Prevention Confinement, immobility, incontinence, malnutrition, decreased level of consciousness or confusion, obesity, diabetes mellitus, dehydration, edema, excessive sweating, and extreme age Prevention Pressure relief, positioning, padding, use of pressure relief devices, adequate nutrition, and excellent skin care deWit Medical Surgical Nursing 8/19/2013

Pressure Ulcers (cont.) Braden scale system or the Norton system National Pressure Ulcer Advisory Panel (NPUAP) staging system for classification Suspected deep tissue injury Stage I Stage II Stage III Unstageable The National Pressure Ulcer Advisory Panel (NPUAP) has updated pressure ulcer definitions for the prediction and prevention of pressure ulcers and a staging system for classification: Suspected deep tissue injury: Intact skin with a purple or maroon discoloration. Tissue may be firm, boggy, painful, cool or warm. Stage I: An area of intact skin that is reddened, deep pink, or mottled that does not blanch (Figure 43-10). Stage II: Partial-thickness skin loss involving the epidermis and/or dermis. The skin appears blistered or abraded, or has a shallow crater. The area surrounding the damaged skin is reddened and probably will feel hot or warmer than normal (Figure 43-11). Stage III: The skin is ulcerated. There is a crater-like ulcer, and the underlying subcutaneous tissue is involved in the destructive process. The ulcer may or may not be infected. Bacterial infection is almost always present at this stage, however, and accounts for continued erosion of the ulcer and the production of drainage (Figure 43-12). Stage IV: There is deep ulceration and necrosis involving deeper underlying muscle and possibly bone tissue. The ulcer can be dry, black, and covered with a tough accumulation of necrotic tissue, or it can be made up of wet and oozing dead cells and purulent exudates. Depth can be determined (Figure 43-13). Unstageable: Full thickness wounds with eschar and/or tissue that obscures depth determination. deWit Medical Surgical Nursing 8/19/2013

Stage I Pressure Ulcer See Figure 43-11 on p. 980. deWit Medical Surgical Nursing 8/19/2013

Stage II Pressure Ulcer See Figure 43-12 on p. 980. deWit Medical Surgical Nursing 8/19/2013

Stage III Pressure Ulcer See Figure 43-13 on p. 980. deWit Medical Surgical Nursing 8/19/2013

Stage IV Pressure Ulcer See Figure 43-14 on p. 980. deWit Medical Surgical Nursing 8/19/2013

Treatment and Nursing Interventions for Pressure Ulcers Débridement Cleansing and dressing Other treatment methods Documentation and Pressure Ulcer Scale for Healing (PUSH) tool deWit Medical Surgical Nursing 8/19/2013

Color of Purulent Exudate and Probable Pathogen COLOR EXUDATE MAY INDICATE Beige with a fishy odor Proteus Brown with a fecal odor Bacteroides Creamy yellow Staphylococcus Green-blue with a fruity odor Pseudomonas See Table 43-2 on p. 981. deWit Medical Surgical Nursing 8/19/2013