Pressure Ulcers

Front 1

Factors affecting wound healing:

Back 1

Age
– Older adults have less
subcutaneous tissue.
• Nutrition
– 0.8 g/kg of protein per day is
needed for wound healing.
• Infection
– Increases metabolic demands.
• Obesity
– Adipose tissue is harder to suture.

Front 2

Factors affecting wound healing:

Back 2

Smoking
– Constricts vessels and decreases oxygenation of tissue.
• Chronic disease
– Diabetes mellitus
– Congestive heart failure
– Chronic obstructive pulmonary disease.
• Coughing, constipation, laughing, and sneezing produce wound stress

Front 3

Stage 1 Pressure ulcer

Back 3

Nonblanchable erythema of intact skin

Front 4

Stage 2 Pressure ulcer

Back 4

A blister, cut, or superficial open area

Front 5

Stage 3 Pressure ulcer

Back 5

Full-thickness deep crater with
damage to underlying
subcutaneous layer

Front 6

Stage 4 Pressure ulcer

Back 6

Damage to muscle and
underlying structures with tissue
necrosis

Front 7

Unstageable

Back 7

Ulcers for which stage cannot
be determined because eschar
or slough obscures the wound

Front 8

Manifestations of Wound Infection

Back 8

Foul-smelling drainage
• Purulent drainage
– Yellow or green in color
• Edges of wound are red and warm and not well-approximated
• Client is febrile, tachycardic, or has an elevated WBC count

Front 9

Primary intention

Back 9

– Wound edges approximate

Front 10

Secondary intention

Back 10

- Loss of tissue
– Pressure ulcer

Front 11

Dehiscence

Back 11

– Separation or opening of a surgical wound

Front 12

Evisceration

Back 12

- Protrusion of abdominal organs from an open surgical wound
– Considered a medical emergency

Front 13

Tissue ischemia

Back 13

– Obstruction of capillary blood flow

Front 14

Eschar

Back 14

– Black necrotic material/tissue

Front 15

Sanguineous

Back 15

– Bloody drainage

Front 16

Proliferative Phase

Back 16

New epithelial cells

Front 17

Hydrogel

Back 17

Provides moist wound bed for healing

Front 18

Hydrocolloid

Back 18

Dressing absorbing exudates

Front 19

Wound Irrigation

Back 19

Irrigations are a special way of cleansing wounds.
– An irrigating syringe is used to flush the area with constant low
pressure flow of solution.
– The gentle washing action of the irrigation cleanses a wound of
exudate and debris.
• Irrigations are particularly useful for open, deep wounds, or wounds
involving an inaccessible body part, such as the ear canal, or a sensitive
body part, such as the conjunctival lining of the eye.
• Sterile technique is required
during wound irrigation.

Front 20

Wound Irrigation

Back 20

A 35 mL syringe with a 19-gauge needle should be used to deliver the
solution.
– It is important to never occlude a wound opening with a syringe.
• Can introduce irrigant into a closed system, which causes tissue
damage and discomfort.
• Always irrigate a wound with the syringe tip over but not in the drainage
site.
– Make sure the fluid flows directly into the wound and not over a
contaminated area before entering the wound.
• The skill of wound irrigation cannot be delegated.
– Monitoring and care of any wound is the responsibility of the nurse.

Front 21

Wound Irrigation Steps

Back 21

Monitor the client’s level of pain. Administer prescribed analgesic 30 to
45 min before starting irrigation procedure.
2. Review recent recording of signs and symptoms related to the client’s
wound, including skin condition, elevated temperature, drainage, odor,
and size of wound.
3. Perform hand hygiene.
4. Position client comfortably to allow gravitational flow of irrigating solution
through wound and into collection receptacle. Position client so that
wound is vertical to collection basin.
5. Warm irrigation solution to approximate body temperature.
6. Apply gown, goggles and mask if needed.

Front 22

Wound irrigation continued

Back 22

Put on clean gloves to remove soiled dressing. 7. Discard dressing and
then gloves.
8. Put on sterile gloves.
9. Irrigate wound using continuous pressure until solution running into basin
is clear.
10.Dry wound edges with gauze.
11.Apply appropriate dressing.
12.Remove goggles, gown, gloves, and mask (if worn). Perform hand
hygiene.
13.Assist client to comfortable position.
14.Observe for presence of retained irrigant (can be a source of infection).