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15 Cards in this Set

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develpop ment of pressure ulcers
- redness is beginning
-capillaries congested BC impaired blood flow
-redness= w/in 1-2hrs with healthy skin/ adquate nutrition
risk factors
- malnourished
- obese
- aged
-circulatory disease
add.risk factors
-imobilty - shearing forces
shearing forces
down and foward pressure
when:
1. pt slumps
2. boosting pt in bed
first step in prevention

at risk: asses QD
TO IDENTIFY THOSE WHO ARE AT RISK :
* NORTON SCALE
< 14 ^ "chance of"

> 14 lowers " "
pressure ulcer prevention protocol
-follow written scedule
-turn Q 2 hrs ^ x's if redness ^
-shift weight every 15 minutes , repositioned hourly
- bed linens
* dry *w/o wrinkles
-cleasne skin
* when soiled
*reguler intervals
*warm water
* mild soap
prevention cont...
mosturizers, lubricants , protective films, bariers & dressings
why ? to reduce friction
a. when pt in bed ?

b.speacial mattress
why? reduce pressure
a. lower hed of bed,so no sliding , shearing force

b. egg crate foam( 2 inch)
stacic air ,
alternating air,
gel
fliuidized air
water mattress
a. to prevent shearing forces FEET
B. PREVENT HEEL PRESSURE
C. protect skin moisture
A. SHEEPSKIN BOOTS

B.PILLOWS/WEDGES
c.absorbent pads/briefs
for incontinece
a enhance mobilty
b. best preventative measure
c. on pressure pts
D. DONT ELEVATE HEELS WITH...
a. trapeze bars
b. position change(frequent)
c. DONT MASSAGE D. RINGS
stage 1 -
*non blanching
*erethyma *intact skin
* heralding lesion
* color- red to cynosis
* skin reflects objects of pressure
* hardening of tissue
* heat
* epidermis
* reversible
A. STAGE 11
A. EPIDERIMIS / DERMIS
* SHALLOW ULCER> has braod , irregular, painful , warm
*BLISTERED * CRACKED/ABRADED
B. STAGE 111
B. dermis/suabcutaneous
skin loss: damage/necrosis
sore: crater like
epidermis: thickens, rolls over toward ulcer base
wound: infected, open, draining,loss of fluid & protein
s/s: fever ,dehydration, anemia , ^ WBC's
c.stage 4
skin loss: FULL
detruction: muscle,maybe bone
infected: usually
s/s: black . excudation , foul odor,
drainage: purluent
TREATMRNT
1st step :is continuing preventative measures
a. stage 1 & 2
. cant heal w/o relief of pressure
a. clean mild soap /normal saline
* no paste creams ointments
why? may promote infection

may harm: alchohol, antiseptic topical /oral antibotics massage, heat lamp

most imp dressing:
moist,
body temperature,
allows oxygen,
NO carbon dioxide