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31 Cards in this Set
- Front
- Back
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Describe the economic consequences of pressure ulcers (5)
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1. 1.5 -3mil people with pressure ulcers (60% in hospital)
2. 3.5-5 Days longer stay in hospital if pt develops PU 3. 5k-60k per incident of PU 4. 50% inc. in nursing care costs 5. Medicare will pay for mattresses but pay if ulcer develops in the hospital |
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Describe the Formation of Pressure Ulcers: (3)
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1. External Pressure - Bed/Chair/Pillow
2. Intensity of Pressure - body weight 3. Duration of Pressure - little as 2hr. Ischemia - blood deficiency in 1 area |
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Risk factors for Pressure Ulcers:
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**1.Immobility - biggest risk
2. Nutrition/Hydration (albumin, vit c, glucose, iron, zinc) 3. Moisture - Maceration 4. Mental Status - confusion, apathetic, cannot feel pain 5. Age- more diseases (heart, diabetes), fractures, skin durability |
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Contributing Factors to Pressure Ulcers(10):
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Dehydration
Incontinence - bowel movements Skin Hygiene Diabetes Diminished Pain Awareness Fractures Immunosuppressants Poor Circulation Previous Ulcers Obiestiy/Thin |
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Stage I Pressure Ulcer
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Redness on skin
does not go away when turned nonblanchable |
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Stage I Treatment
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Pressure Relieving Devices
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Stage II Pressure Ulcer
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Partial Break in the skin
Dermis or Epidermis |
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State II Treatment
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Hydrocoloid - maintain moist envir.
Transparent Film |
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Stage III Pressure Ulcer
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Subcutaneous Tissue Exposed
Slough + Necrotic Tissue Possible Tunneling + Undermining Possible |
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Stage III Treatment
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Wet to dry Dressing
Protolytic Enzyme Debride |
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Stage IV Pressure Ulcer
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Muscle + Bone Exposed
Necrotic (Dead Tissue) Tunneling + Undermining Possible |
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Stave IV Treatment
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Surgery
Skin Graft Wound Vac Protolytic Enzyme Debride |
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Red Wounds
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Clean Granulation Tissue
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Yellow Wounds
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Slough (fibrous) Tissue
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Black Wounds
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Necrotic Tissue
ESCHAR (scab like) |
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Assessment: Wound (Stage I)
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Redness on skin and unblanchable
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Diagnosis: Wound (Stage I)
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Wound R/T immobility AEB non-blanchable skin when pressed.
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Planning: Wound (Stage I)
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Pts. wound will become blanchable after 1 week after frequent turning and pressure relieving
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Implementation Wound (Stage I)
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Pt. will be turned Q2Hr and pressure relieving devices will be applied Q8Hr
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Evaluation Wound (Stage I)
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Pts. goals were met on 11/11/2011, skin is once again blanchable.
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Identify the nutritional requirements of clients with healing pressure ulcers:
(5) |
1. Protein-promote wound healing (albumin)\
2. Vit C - inc. capillary strength 3. Glucose - 70-110 4. Iron - Transport of O2 5. Zinc - Granulation Tissue Formation |
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type of wound that is cutting or or sharp instrument; wound edges in close approximation and aligned:
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Incision
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type of wound that was caused by a blunt instrument. The overlying skin remains intact, with injury to the underlying soft tissue. Possible result in bruising and or hematoma
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Contusion
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Type of wound that is caused by friction, rubbing or scraping epidermal layers of skin; top layer of skin is abraded:
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Abrasion
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Type of wound where the tearing of skin and tissue with blunt or irregular instrument; Tissue is not aligned; often with loose flaps of skin and tissue:
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Laceration
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Type of wound caused by a blunt or sharp instrument puncturing the skin; intentional (venipuncture), or accidental
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Puncture
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Type of wound that is described as tearing a structure from normal anatomical positions; Possible damage to blood vessels, nerves, and other structures:
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Avulsion
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Type of wound that is caused by secretion of exotoxins or release of endotoxins by living organisms
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Microbial
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Type of wound that is caused by a toxic agent such as drugs, aids, alcohols, metals, and substances released from cellular necrosis
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Chemical
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Type of wound that is caused by high and low temperatures; Cellular necrosis is a possible result:
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Thermal
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Type of wound that is caused by ultraviolet light or radiation exposure
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Irradiation
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