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9 Cards in this Set
- Front
- Back
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bony prominences most susceptable to skin breakdown
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Sacurm
Heels Trochanteric areas |
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Four physical factors that can lead to the development of pressure ulcers:
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(a) Pressure – Mild pressure can produce ischemia in tissue after only two hours. This ischemia can then lead to tissue necrosis
(b) Shear - A shearing force is produced where the skin is against a fixed exterior surface while the subcutaneous tissues are subjected to lateral forces (c) Friction – When the skin moves across another surface, abrasions can occur and cause burns (d) Moisture – Moisture can lead to tissue maceration. If urinary or fecal incontinence is present, this can add a chemical irritant |
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Risk factors for skin breakdown
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Recent hospitalization
Fracture CVA Low BMI Fecal/urinary incontinence Low serum albumin Immobility Bed/chair bound DM Anemia Dry skin |
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Stage I: pressure ulcer
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blanchable hyperemia
(47%) |
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Stage II: pressure ulcer
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extension of ulcer through the epidermis
(33%) superficial and presents clinically as an abrasion, blister, or shallow crater |
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Stage III: pressure ulcer
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(14%) full-thickness skin loss with damage or necrosis of SC tissue
Presents clinically as a deep crater with or without undermining of adjacent tissue. |
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Stage IV: pressure ulcer
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(6%) full-thickness rounds with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures
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Principles of Treatment of pressure ulcers
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Debride wound
Clean wound Use solutions that DON’T kill cells DON’T use solutions that are cytotoxic i.e. hydrogen peroxide, Dahen’s Solution, or Betadine Irrigate wound, using minimal force Cover wound with appropriate dressing Moist wound environment increase healing 40% faster than dry wounds Any therapy that dehydrates the wound is detrimental |
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Types of Topical dressings
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Polymer films
Polymer foams Hydrogels Hydrocolloids Alginates Biomembranes SHOULD be left in place until wound fluid is leaking from the sides….ideally a period of days |
