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Friction and shearing
Inadequate nutrition
Fecal and urinary incontinence
Decreased mental status
Dimished sensation
Excessive body heat
Advanced age
Chronic mental conditions
Poor lifting and transferring techniques
Incorrect positioning
Hard support surfaces
Incorrect application of pressure-relieving devices
Risk Factors for Pressure ulcers
Braden Scale for predicting pressure sore risk

Nortons Pressure area risk Assessment
Risk assessment Tools
Providing nutrition
Maintaining skin hygiene
Avoiding skin trauma
Providing supportive devices
Measure to prevent pressure ulcers
Fluid intake Protein, vitamins, zinc Dietary consult Weight/lab data monitoring
Providing Nutrition
Mild cleansing agents Avoid hot water Moisturizing lotions/skin protection Reduce irritants
Maintaining Skin Hygiene
Smooth, firm surfaces Semi-Fowler’s position Frequent weight shifts Exercise and ambulation Lifting devices Reposition q 2 hours Turning schedule
Avoiding Skin Trauma
Mattresses Beds Wedges, pillows Miscellaneous devices
Providing Supportive Devices
Inspect pressure areas for discoloration and capillary refill or blanche response Inspect pressure areas for abrasions and excoriations Palpate the surface temperature over the pressure area sites Palpate bony prominences and dependent body areas for the presence of edema
Steps to assessing a Pressure Site
Location of the ulcer related to a bony prominence Size of ulcer in centimeters including length (head to toe), width (side to side), and depth Presence of undermining or sinus tracts Stage of the ulcer Color of the wound bed Location of necrosis or eschar Condition of the wound margins Integrity of surrounding skin Clinical signs of infection
Assessment and Documentation of Pressure Ulcers
Minimize direct pressure Schedule and record position changes Provide devices to reduce pressure areas Clean and dress the ulcer using surgical asepsis Never use alcohol or hydrogen peroxide Obtain C&S, if infected Teach the client Provide ROM exercise
Treating Pressure ulcers
Stage I: Nonblanchable erythema signaling potential ulceration
Stage II: partial thickness skin loss (abrasion, blister, or shallow crater) involving the epidermis and possibly the dermis
stage III: full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue
, stage IV: full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures, such as a tendon or joint capsule. Undermining and sinus tracts may also be present.
Inadequate venous return over a prolonged period of time ↑ venous pressure = impaired arterial circulation ↓ O2 and nutrients = cell death Skin atrophies, subq fat deposits necrose = hard, shiny skin RBC’s in the breakdown = brown skin, & ulcers develop Poor venous circulation also = ↑ risk for ?
Chronic Venous Insufficiency
Over medial or interior ankle Superficial, pink in color Skin has a brown discoloration, cyanotic when on it Normal skin temperature Usually edematous Mild, aching pain Normal pulses
Venous ulcers
Over the toes, feet, shin Ulcer is deep and pale Skin is pale when elevated, red when walking Skin is cool to touch No to little edema Pain is severe and constant May get infected (gangrene) Pulses are decreased or absent
Arterial Ulcers
Elevate the legs Walk, avoid sitting & standing for long periods Do not cross your legs Do not wear restrictive garments Wear elastic hose as prescribed Keep skin on feet & legs clean, soft & dry Prevent accidents and injuries & inspect legs and feet daily
Teaching for Chronic Venous Insufficiency
NS wet to moist gauze dressings Possible dilute topical antibiotic Semi- rigid boot (Unna boot) applied to the foot and lower boot Bony prominences are padded Boot changed q 1-2 weeks depending on drainage amounts from the ulcer Hyperbaric Chamber treatments Surgery may required for a very large, non-healing
Medical care of Stasis Ulcers
Tissue surfaces closed Minimal or no tissue loss Formulation of minimal granulation and scarring
Primary Intention healing
Extensive tissue loss Edges cannot be closed Repair time longer Scarring greater Susceptibility to infection greater
Secondary Intention Healing
Initially left open Edema, infection, or exudate resolves Then closed
tertiary Intention Healing (delayed primary intention)
Immediately after injury; lasts 3 to 6 days Hemostasis Phagocytosis
Inflammatory Phase of Wound Healing
From post injury day 3 or 4 until day 21 Collagen synthesis Granulation tissue formation
Proliferative Phase of Wound Healing
From day 21 until 1 or 2 years post injury Collagen organization Remodeling or contraction Scar stronger
Maturation Phase of wound healing
Material such as fluid and cells that have escaped from blood vessels during inflammatory process Deposited in tissue or on tissue surface 3 major types Serous Purulent Sanguineous (hemorrhagic)
Mostly serum Watery, clear of cells (ie. Fluid in a blister)
serous Exudate
Thicker Presence of pus Color varies with organisms
Purulent Exudate
Hemorrhagic Large # of RBC’s Indicates severe damage to capillaries
Sanuineous Exudate
Bloody Serous fluid
Serous Sanguineous
Serosanguineous Clear and blood-tinged drainage Purosanguineous Pus and blood
Mixed exudate
Hemorrhage Infection Dehiscence Evisceration
Complications of wound healing
Age Nutritional status Lifestyle Medications
Factors Affecting wound healing
Leukocyte count Hemoglobin level Blood coagulation studies Serum protein analysis Albumin level Results of wound culture and sensitivities
Assessments of lab data used in woud care
check H and H (hemoglobin and hematocrit) checks the blood level for blood loss
Checked anytime surgery is performed
Red (protect) Yellow (cleanse) Black (debride)
RYB Color Guide of wound care
Fluid intake Protein, vitamin, and zinc intake Dietary consult Nutritional supplements Monitor weight/lab values

Prevent entry of microorganisms

Prevent transmission of pathogens
Promoting wound healing and preventing complications
Done at every dressing change (or per agency policy Measure the wound length x width x depth Note and measure any tunneling or tracking Color of the wound and surrounding skin Drainage: color, amount.  Any odor? What was used to clean and dress the wound Any pain to the patient?
Documenting a wound
Vasodilation Increases capillary permeability Increases cellular metabolism Increases inflammation Produces sedative effect
effects of heat
Muscle spasms Inflammation Pain Contracture Joint stiffness
Indications of Heat
Vasoconstriction Decreases capillary permeability Decreases cellular metabolism Slows bacterial growth Decreases inflammation Local anesthetic effect
Effects for cold
Muscle spasms Inflammation Pain Traumatic injury
Indications for Cold
Impetigo- superficial infection of skin caused by staphylococci, streptococci, and multiple bacteria Folliculitis- infection of bacterial or fungal origin arising within the hair follicle Furuncles- acute inflammation spreading to surrounding dermis  Carbuncles- abscess of skin and subcutaneous tissue
Inflammatory reaction of skin to physical, chemical, or biological agents Noninfectious Inflammatory Dermatoses Psoriasis
Enters through a break in the skin barrier Allows bacteria to enter and release toxins in the subcutaneous tissue Localized swelling, redness and pain Also systemic reaction of fever, chills and sweating Treatments include oral and IV antibiotic therapy (depending on severity) Nursing management: elevate effected areas, apply warm moist packs, & education in prevention of a re-occurrence
Herpes Zoster (Shingles) - infection caused by varicella-zoster virus Herpes Simplex- Type 1  typically occurs on mouth Type 2 typically occurs on genitals
viral skin Infections
Tinea Pedis- Athlete’s Foot Tinea Corporis- Ringworm of the Body Tinea Capitis- Ringworm of the Scalp Tinea Cruris- Ringworm of the Groin
fungal (mycotic) infections
Pediculosis- infestation of lice Pediculosis Capitis- head lice Pediculosis Corporis and Pubis- infestation of body and pubic region Scabies- infestation by itch mite Sarcoptes scabiei
Parasitic skin Infestations
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