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

2. 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.
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8/19/2013

3. 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.
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4. 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
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8/19/2013

5. 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.
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8/19/2013

6. Stage I Pressure Ulcer See Figure 43-11 on p. 980.
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7. Stage II Pressure Ulcer
See Figure on p. 980.
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8. Stage III Pressure Ulcer
See Figure on p. 980.
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9. Stage IV Pressure Ulcer
See Figure on p. 980.
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10. Treatment and Nursing Interventions for Pressure Ulcers
Débridement
Cleansing and dressing
Other treatment methods
Documentation and Pressure Ulcer Scale for Healing (PUSH) tool
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11. 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.
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8/19/2013