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25 Cards in this Set
- Front
- Back
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Pressure Ulcers
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[AKA Decubitis ulcer]
- “A pressure ulcer is a localized area (usually over a bony prominence) of tissue necrosis caused by unrelieved pressure that occludes blood flow to the tissues” |
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Tissue damage occurs when…
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- Sustained pressure on an area
supporting the body is high enough to close capillaries (capillary closing pressure). - Normal capillary pressure ranges from 16 to 32 mm Hg - The result is reduced blood supply and eventual death of skin & underlying muscles. |
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PU & Tissue Tolerance Extrinsic factors:
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– Shearing force – pressure exerted on the skin
when it adheres to the bed & the skin layers slide in the direction of body movement) – Friction – two surfaces rubbing against each other – Excessive moisture – Surgical procedure > 4 hours |
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PU & Tissue Tolerance Intrinsic Factors:
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– Poor Nutrition
– Age - >70 years – Co-morbidities – Stress – Previous history of Pressure Ulcer – Smoking |
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PU Stage I:
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- Non-blanchable
erythema of intact skin, the heralding lesion of skin ulceration - In individuals with darker skin, discoloration of skin may be purplish/bluish accompanied by localized heat, edema, induration or hardness |
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PU Stage II:
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- Partial-thickness skin
loss involving epidermis, dermis or both. - The ulcer is usually superficial & presents clinically as an abrasion, blister, or shallow crater. |
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PU Stage III:
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- Full- thickness skin loss
involving damage, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer clinically presents as a deep crater with or without undermining of adjacent tissue. |
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PU Stage IV:
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- Full-thickness skin loss
with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (eg tendon joint capsules) - Undermining & sinus tracts also may be associated with stage IV ulcers |
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PU & Activity
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- Stage each of the following Ulcers
Common Sites Surgical procedure > 4 hours Pressure Ulcer Prevention and Risk Assessment PU & Prevention - Pressure ulcer prevention involves 3 tasks: – Proper assessment of the patients’ risk factors using a reliable tool (such as the Braden scale) – Reduction of Pressure – Aiding in an increase in the patients tissue tolerance |
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Pressure Ulcer Assessment
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- Stage/Depth
- Location - Size (mm,cm) - Odour - Exudate - Appearance of wound bed; and - Condition of the - Sinus tracts/undermining/ tunneling surrounding skin (periwound) & wound edges |
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Braden Scale
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- Scores can range from 6 – 23
- The lower the numeric score on the scale and in each subscale, the higher the patient’s predicted risk of developing a pressure ulcer Scoring the Braden Scale - Two methods: – Total the score - No risk (19-23); - At risk (15-18); - moderate risk (13-14); - high risk (10-12); - very high risk (9 or below) |
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Scoring the Braden Scale
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- Two methods:
– Deficit/ No deficit - Deficit = any score less than perfect - No deficit = perfect score - Also tally the number of deficits - Note which subscales involve a deficit. Activity - Using the Braden Scale, assess & determine the following patients risk for developing pressure ulcers |
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PU & Pressure Reduction
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- Involves:
– Selection of appropriate bed and seating surfaces – Frequent patient turning - Good evidence of the effectiveness of high specification foam over standard hospital foam - Pressure relieving mattresses in the operating theatre reduced the incidence of pressure sores post op - Relative merits of alternating & constant low pressure & of the different alternating pressure devices are unclear - Limited evidence suggests that low air loss beds reduce the incidence of pressure sores in intensive care |
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PU & Products:
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- Pressure reducing surface: A surface
that lowers the interface pressure between the body surface & the resting surface but does not consistently reduce pressure to less than capillary closing pressure - Pressure relieving device : A surface that consistently reduces pressure between the body surface & the resting surface below capillary closing pressure |
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PU & Patient repositioning
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- Turn patients every 2 hours when
immobilized - Never sit or lie on reddened skin - Avoid lying directly on trochanter - Reposition every 15 minutes in a chair - What other positioning techniques or measures could a nurse use to prevent the occurrence of a pressure sore? – Consider ways of reducing shearing forces and friction – Consider the individual in bed and in a chair |
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PU & Moisture:
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– Cleanse the skin when soiled
– Use protective sprays and powders – Implement a toileting regime – Pat skin dry, do not rub – Avoid catheters – Individualize bathing frequency (Use mild cleansing agent, avoid hot water & friction) – Use moisturizers for dry skin. – Do not massage over bony prominences |
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PU & Friction/Shear:
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– Prevent skin tears and injury via protection
– Apply padding – Lift the patient, avoid dragging Increasing Patient Tissue Tolerance - Nutrition: – Oral feedings must be adequate in calories, proteins, fluids, vitamins & minerals – For adults: - 30-35 calories/kg/day - 1.25-1.5 grams of protein/kg/day – Add in enteral & parenteral nutrition for prevention & treatment of pressure ulcers Pressure Ulcer Treatment - Keep person off the pressure ulcer - Use pressure reducing or relieving devices - Keep a pressure ulcer slightly moist, rather than dry, to enhance re-epithelialization - Control pain - Continue turning the patient every 2 hours - Avoid the affected area |
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PU & Equipment
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- Good evidence of the effectiveness of airfluidized
and low air loss devices as treatments (based on six RCTs) - Seat cushions have not been adequately evaluated |
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PU & Cleansing
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- Pressure ulcers should be cleaned with
noncytotoxic solutions that do not kill/damage cells especially fibroblasts - Solutions such as Dakin’s solution (sodium hypochlorite), acetic acid, povidone iodine & hydrogen peroxide (H2O2) are cytotoxic Dressings |
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PU & Cleansing- Stage I:
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Transparent film dressing, thin
hydrocolloid dressing [protect skin] |
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PU & Cleansing - Stage II:
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Moist wound dressing,
transparent film dressing, hydrocolloid dressing [promote re-epithelialization] |
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PU & Cleansing - Stage III & IV:
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Debridement, hydrogel,
hydrocolloid, alginate, mesal [promote granulation tissue to fill in wound] Pressure Ulcers Pain |
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Pressure Ulcer Pain
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- Affects between 12-100% of patients with
pressure ulcers - Is under treated - Increases as stage of ulcer increases |
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PU & Documentation
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- Note:
– Location – Size – Shape – Edges and – Undermining – Skin colour surrounding – Depth – Base – Necrotic tissue – Granulation tissue – Edema and Irritation – What was done – Products used – Pain |
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Krasner’s chronic wound pain model:
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- 3 types of chronic wound pain
– noncyclic acute pain – cyclic acute pain – chronic wound pain |
