BASIC HUMAN NEEDS ALTERATIONS IN SKIN INTEGRITY PRESSURE ULCERS.
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BASIC HUMAN BASIC HUMAN NEEDSNEEDS
ALTERATIONS IN ALTERATIONS IN SKIN INTEGRITYSKIN INTEGRITY
PRESSURE PRESSURE ULCERSULCERS
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Skin IntegritySkin Integrity
Skin/Integumentary system is the Skin/Integumentary system is the body’s largest organ, 1/6body’s largest organ, 1/6thth of TBW of TBW
Protects against disease causing Protects against disease causing organismsorganisms
Sensory organ for temp, pain, touchSensory organ for temp, pain, touch Synthesizes Vitamin DSynthesizes Vitamin D Injury to skin poses a risk to safety Injury to skin poses a risk to safety
and triggers a complex healing and triggers a complex healing processprocess
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Normal IntegumentNormal Integument
2 principle layers in relation to 2 principle layers in relation to wound healingwound healing
EpidermisEpidermis DermisDermis Separated by basement membraneSeparated by basement membrane
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EpidermisEpidermis
Outer layer has several layers within Outer layer has several layers within itit
Stratum CorneumStratum Corneum Stratum LucidemStratum Lucidem Stratum GranulosumStratum Granulosum Stratum SpinosumStratum Spinosum Basal cell layerBasal cell layer
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DermisDermis
Inner layer of skinInner layer of skin Provides tensile strength & Provides tensile strength &
mechanical support & protection to mechanical support & protection to underlying muscle, bones, and organsunderlying muscle, bones, and organs
Contains mostly connective tissueContains mostly connective tissue Also includes blood vessels, nerves, Also includes blood vessels, nerves,
sensory nerve cells, lymphatics, sensory nerve cells, lymphatics, collagencollagen
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Skin FunctionsSkin Functions
Epidermis-functions to re-surface Epidermis-functions to re-surface wounds & restore the barrier wounds & restore the barrier against bacteriaagainst bacteria
Dermis-functions to restore Dermis-functions to restore structural integrity-collagen& structural integrity-collagen& physical properties of skinphysical properties of skin
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Alarming FactsAlarming Facts Pressure ulcers were the primary diagnosis Pressure ulcers were the primary diagnosis
in about 45,500 hospital admissions (2006)in about 45,500 hospital admissions (2006) Among hospital admissions listing pressure Among hospital admissions listing pressure
ulcers as a primary diagnosis, 1 in 25 ulcers as a primary diagnosis, 1 in 25 admissions ended in death.admissions ended in death.
Pressure ulcer related hospitalizations are Pressure ulcer related hospitalizations are longer and more expensive than other longer and more expensive than other hospitalizations. Avg 5 day hospitalization hospitalizations. Avg 5 day hospitalization $10,000, average pressure ulcer related stay $10,000, average pressure ulcer related stay extends to 14 days and costs up to $20,000.extends to 14 days and costs up to $20,000.
Source: AHRQ (www.ahrq.gov)Source: AHRQ (www.ahrq.gov)
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Pressure UlcersPressure Ulcers
New NPUAP terminology (2007) New NPUAP terminology (2007) www.npuap.orgwww.npuap.org
A pressure ulcer is a localized injury to A pressure ulcer is a localized injury to the skin and/or underlying tissue usually the skin and/or underlying tissue usually over a bony prominence, as a result of over a bony prominence, as a result of pressure, or pressure in combination with pressure, or pressure in combination with shear and/or friction.shear and/or friction.
A number of contributing factors are also A number of contributing factors are also associated with pressure ulcersassociated with pressure ulcers
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Pressure UlcersPressure Ulcers
Tissues receive oxygen and nutrients Tissues receive oxygen and nutrients and eliminates metabolic wastes via the and eliminates metabolic wastes via the bloodblood
Any factor that interferes with this Any factor that interferes with this affects cellular metabolism and cell lifeaffects cellular metabolism and cell life
Pressure affects cellular metabolism by Pressure affects cellular metabolism by decreasing or stopping tissue decreasing or stopping tissue circulation resulting in tissue ischemiacirculation resulting in tissue ischemia
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Causes of Pressure Causes of Pressure UlcersUlcers
Pressure > ischemia > edema > Pressure > ischemia > edema > inflammation > small vessel inflammation > small vessel thrombosis > cell deaththrombosis > cell death
Shear – trauma caused by tissue Shear – trauma caused by tissue layers sliding across each other, layers sliding across each other, results in disruption or angulation of results in disruption or angulation of blood vesselsblood vessels
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Pressure Ulcer Pressure Ulcer Contributing FactorsContributing Factors
Friction/ShearFriction/Shear Poor NutritionPoor Nutrition IncontinenceIncontinence MoistureMoisture Co-existing Medical ConditionsCo-existing Medical Conditions
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PressurePressure
Tissue damage occurs when Tissue damage occurs when pressure exerted on the capillaries is pressure exerted on the capillaries is high enough to close the capillarieshigh enough to close the capillaries
Capillary closing pressure is the Capillary closing pressure is the pressure needed to close the pressure needed to close the capillary > 32 mmHgcapillary > 32 mmHg
After a period of ischemia light After a period of ischemia light toned skin undergoes 2 hyperemic toned skin undergoes 2 hyperemic changeschanges
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HyperemiaHyperemia
Normal Reactive Hyperemia-visible Normal Reactive Hyperemia-visible effect of localized vasodilatation effect of localized vasodilatation (REDNESS) area will blanch with (REDNESS) area will blanch with fingertip pressure and redness lasts less fingertip pressure and redness lasts less than 1 hourthan 1 hour
Abnormal Reactive Hyperemia-Abnormal Reactive Hyperemia-excessive vasodilatation and induration excessive vasodilatation and induration (edema) in response to pressure. Skin (edema) in response to pressure. Skin appears bright pink-red. Lasts 1 hour to appears bright pink-red. Lasts 1 hour to 2 weeks2 weeks
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Risk Factors for Pressure Risk Factors for Pressure Ulcer DevelopmentUlcer Development
Impaired Sensory InputImpaired Sensory Input
Impaired Motor FunctionImpaired Motor Function
Altered Level of ConsciousnessAltered Level of Consciousness
Orthopedic DevicesOrthopedic Devices
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Pathogenesis of Pressure Pathogenesis of Pressure UlcersUlcers
Intensity of pressure and capillary Intensity of pressure and capillary closing pressureclosing pressure
Duration and sustenance of pressureDuration and sustenance of pressure
Tissue ToleranceTissue Tolerance
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Pathogenesis of Pressure Pathogenesis of Pressure UlcersUlcers
Bony prominences are most at risk Bony prominences are most at risk (sacrum, heels, elbows, lateral (sacrum, heels, elbows, lateral malleoli, greater trochanter, ischial malleoli, greater trochanter, ischial tuberositiestuberosities
Pressure ulcer forms as a result of Pressure ulcer forms as a result of time/pressure relationshiptime/pressure relationship
Greater the pressure and duration of Greater the pressure and duration of pressure, the greater the incidence pressure, the greater the incidence of ulcer formationof ulcer formation
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Pathogenesis of Pressure Pathogenesis of Pressure UlcersUlcers
Skin and subcutaneous tissue can Skin and subcutaneous tissue can withstand some pressurewithstand some pressure
Tissue will over time become Tissue will over time become hypoxic and ischemic injury will hypoxic and ischemic injury will occuroccur
If the pressure is above 32mmHg If the pressure is above 32mmHg and remains unrelieved to the point and remains unrelieved to the point of tissue hypoxia, the vessel will of tissue hypoxia, the vessel will collapse and thrombosecollapse and thrombose
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Pathogenesis of Pressure Pathogenesis of Pressure UlcersUlcers
If circulation is restored before this If circulation is restored before this critical point, circulation to tissue is critical point, circulation to tissue is restored (Reactive Hyperemia)restored (Reactive Hyperemia)
Skin has a greater ability to tolerate Skin has a greater ability to tolerate ischemia than does muscle, hence ischemia than does muscle, hence true pressure ulcers begin at bone true pressure ulcers begin at bone with pressure related to muscle with pressure related to muscle ischemia eventually coming through ischemia eventually coming through to epidermis (Shear injury) Sacrum to epidermis (Shear injury) Sacrum and heels most susceptibleand heels most susceptible
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Pressure Ulcer StagingPressure Ulcer Staging
Depth of destroyed tissueDepth of destroyed tissue Does not indicate healingDoes not indicate healing Ulcer covered by necrotic tissue or Ulcer covered by necrotic tissue or
eschar cannot be staged until eschar cannot be staged until debrideddebrided
NPUAP system used most clinicallyNPUAP system used most clinically Other staging systems existOther staging systems exist
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Stage 1 Pressure UlcerStage 1 Pressure Ulcer
Intact skin with non-blanchable redness of Intact skin with non-blanchable redness of a localized area usually over a bony a localized area usually over a bony prominence.prominence.
Darkly pigmented skin may not have Darkly pigmented skin may not have blanching: its color may differ from the blanching: its color may differ from the surrounding areasurrounding area
The area may be painful, firm, soft, warmer The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.or cooler as compared to adjacent tissue.
Stage I may be difficult to detect in Stage I may be difficult to detect in individuals with darker skin tonesindividuals with darker skin tones
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Stage I TreatmentStage I Treatment
Off-load pressureOff-load pressure
Transparent film dressingTransparent film dressing
Hydrocolloid dressingHydrocolloid dressing
Moisture barrierMoisture barrier
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Stage IIStage II
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Stage 2 Pressure UlcerStage 2 Pressure Ulcer
Partial thickness skin loss involving the Partial thickness skin loss involving the epidermis and/or dermis. epidermis and/or dermis.
The ulcer is superficial and presents The ulcer is superficial and presents clinically as an abrasion, blister, or clinically as an abrasion, blister, or shallow open ulcershallow open ulcer
Presents as shiny or shallow ulcer Presents as shiny or shallow ulcer (red/pink wound bed) without slough or (red/pink wound bed) without slough or bruising. This stage should not be used to bruising. This stage should not be used to describe skin tears, tape burns, perineal describe skin tears, tape burns, perineal dermatitis, maceration or excoriationdermatitis, maceration or excoriation
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Stage II TreatmentStage II Treatment
Hydrocolloid dressing: dressing of Hydrocolloid dressing: dressing of choice in minimally draining stage II choice in minimally draining stage II ulcerulcer
Absorptive dressings (Foam) Absorptive dressings (Foam) draining woundsdraining wounds
Hydrogel: Healing woundsHydrogel: Healing wounds Off-load pressureOff-load pressure
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Stage IIIStage III
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Stage IIIStage III
Full thickness skin loss involving damage Full thickness skin loss involving damage or necrosis to subcutaneous tissue that or necrosis to subcutaneous tissue that may extend down to, but not through may extend down to, but not through underlying fasciaunderlying fascia
Ulcer presents as a deep crater with or Ulcer presents as a deep crater with or without undermining or tunneling of without undermining or tunneling of adjacent tissueadjacent tissue
Slough tissue may be present but does Slough tissue may be present but does not obscure the depth of tissue lossnot obscure the depth of tissue loss
Depth varies by anatomical locationDepth varies by anatomical location
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Stage III TreatmentStage III Treatment
Requires physician order for Stage III Requires physician order for Stage III or IVor IV
Draining vs. Non-drainingDraining vs. Non-draining Necrotic vs. GranulatingNecrotic vs. Granulating Draining wounds-Absorptive dressingsDraining wounds-Absorptive dressings Granulating wounds-HydrogelGranulating wounds-Hydrogel Necrotic wounds-Require debridement Necrotic wounds-Require debridement
(Chemical. Mechanical, Autolytic, (Chemical. Mechanical, Autolytic, Sharp)Sharp)
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Stage IVStage IV
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Stage IVStage IV
Full thickness skin loss with extensive Full thickness skin loss with extensive destruction, tissue necrosis or damage to destruction, tissue necrosis or damage to muscle, bone , or supporting structures muscle, bone , or supporting structures (tendons, joint)(tendons, joint)
Undermining and tunneling are often Undermining and tunneling are often associated with Stage IV ulcersassociated with Stage IV ulcers
Slough or eschar may be present in some on Slough or eschar may be present in some on some parts of the wound bedsome parts of the wound bed
Depth of wound varies by anatomical locationDepth of wound varies by anatomical location Exposed bone or tendon is visible or directly Exposed bone or tendon is visible or directly
palpablepalpable
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Unstagable WoundsUnstagable Wounds
Full thickness tissue loss in which the base Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar tan, gray, green or brown) and/or eschar (tan, brown, black) in the wound bed(tan, brown, black) in the wound bed
The true depth of the wound cannot be The true depth of the wound cannot be determined until slough or eschar is determined until slough or eschar is removed, therefore stage cannot be removed, therefore stage cannot be determined.determined.
Stable eschars serve as the body’s natural Stable eschars serve as the body’s natural biological cover and should not be biological cover and should not be removedremoved
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UnstageableUnstageable
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Deep Tissue InjuryDeep Tissue Injury Purple or maroon localized area of Purple or maroon localized area of
discolored intact or blood filled blister due discolored intact or blood filled blister due to the damage of underlying soft tissue to the damage of underlying soft tissue from pressure or shear.from pressure or shear.
The area may be preceded by tissue that is The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissuecooler as compared to adjacent tissue
May be difficult to detect with darker skin May be difficult to detect with darker skin tonestones
Evolution may include a thin blister over a Evolution may include a thin blister over a dark wound beddark wound bed
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Staging by ColorStaging by Color
BlackBlack
YellowYellow
Pink/RedPink/Red
Mixture of colorsMixture of colors
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Process of Wound Process of Wound HealingHealing
Primary IntentionPrimary Intention
Secondary IntentionSecondary Intention
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Healing by Primary Healing by Primary IntentionIntention
Inflammatory (Reaction)Inflammatory (Reaction)
Proliferative (Regeneration)Proliferative (Regeneration)
Maturation (Re-modeling)Maturation (Re-modeling)
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Healing by Secondary Healing by Secondary IntentionIntention
Healing takes longerHealing takes longer Wounds drain more fluidsWounds drain more fluids Inflammation phase is prolonged, Inflammation phase is prolonged,
chronicchronic Wound becomes filled with fragile Wound becomes filled with fragile
granulation tissue rather than collagengranulation tissue rather than collagen Wound Contraction takes placeWound Contraction takes place More susceptible to infectionMore susceptible to infection
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Complications of Wound Complications of Wound HealingHealing
HemorrhageHemorrhage Infection (Nosocomial)Infection (Nosocomial) DehiscenceDehiscence EviscerationEvisceration Fistula FormationFistula Formation
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Risk Assessment for Risk Assessment for Pressure UlcersPressure Ulcers
Identify at risk populationIdentify at risk population Norton ScaleNorton Scale Gosnell Scale Gosnell Scale Braden Scale- most uses clinically, includes Braden Scale- most uses clinically, includes
6 subscales (sensory perception, moisture, 6 subscales (sensory perception, moisture, activity, mobility, nutrition, friction & shearactivity, mobility, nutrition, friction & shear
6-23 score, <18 at risk in hospitalized 6-23 score, <18 at risk in hospitalized patientspatients
Refer to P&P pg. 1496-1497 for Braden Refer to P&P pg. 1496-1497 for Braden ScaleScale
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Factors Affecting Pressure Factors Affecting Pressure Ulcer FormationUlcer Formation
Shearing forceShearing force FrictionFriction MoistureMoisture Tissue Tolerance FactorsTissue Tolerance Factors NutritionNutrition InfectionInfection Impaired Peripheral CirculationImpaired Peripheral Circulation AgeAge
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Factors that Impair Wound Factors that Impair Wound HealingHealing
AgeAge MalnutritionMalnutrition ObesityObesity Impaired oxygenationImpaired oxygenation SmokingSmoking Diabetes (blood glucose level)Diabetes (blood glucose level) DrugsDrugs RadiationRadiation Wound StressWound Stress
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Nursing ProcessNursing ProcessAssessmentAssessment
Predictive measures-Risk assessment Predictive measures-Risk assessment toolstools
Skin assessment- any areas susceptible Skin assessment- any areas susceptible to pressure sources, (NG, oxygen tubes, to pressure sources, (NG, oxygen tubes, casts, bony prominences)casts, bony prominences)
Tactile Assessment-Blanching red areasTactile Assessment-Blanching red areas Assess mobilityAssess mobility Assess nutritional statusAssess nutritional status
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Wound AssessmentWound Assessment
Location, Size, StageLocation, Size, Stage Wound drainageWound drainage Wound bed, tissue typeWound bed, tissue type Wound edgesWound edges Periwound skinPeriwound skin Presence of undermining, tunnelingPresence of undermining, tunneling
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Wound AssessmentWound Assessment
Anatomical locationAnatomical location Stage-NPUAP stagingStage-NPUAP staging Staging is for pressure ulcers only, Staging is for pressure ulcers only,
other wounds are classified as other wounds are classified as partial or full thicknesspartial or full thickness
Size- Measure length, width, depth Size- Measure length, width, depth in centimetersin centimeters
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Wound AssessmentWound Assessment
DrainageDrainage Amount, color, consistency, odorAmount, color, consistency, odor Scant, moderate, largeScant, moderate, large Serous, serosanguinous, purulent, Serous, serosanguinous, purulent,
yellow, brown, green, clearyellow, brown, green, clear Odor to wound may be indicative of Odor to wound may be indicative of
infectioninfection
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Wound AssessmentWound AssessmentTissue TypeTissue Type
When describing wound bed include % of When describing wound bed include % of each tissue type (50% slough, 50% each tissue type (50% slough, 50% granulation)granulation)
Necrotic tissue-nonviableNecrotic tissue-nonviable Eschar- dry, leathery, black or brownEschar- dry, leathery, black or brown Slough- stringy, cheesy, loose, yellow, tanSlough- stringy, cheesy, loose, yellow, tan Granulation- healthy, viable pink to beefy Granulation- healthy, viable pink to beefy
redred Epithelialization-occurs along wound edges Epithelialization-occurs along wound edges
or as islands inside wound bed, pale pink or as islands inside wound bed, pale pink resurfacing of woundresurfacing of wound
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Wound AssessmentWound AssessmentPeriwound AreaPeriwound Area
Erythema-may mean infectionErythema-may mean infection
Maceration-Whitish, wrinkled Maceration-Whitish, wrinkled appearanceappearance
Indicates presence of excessive Indicates presence of excessive moisturemoisture
Rash- Macular or papular, may indicate Rash- Macular or papular, may indicate fungal infectionfungal infection
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Wound AssessmentWound AssessmentPresence of Presence of
Undermining/TunnelingUndermining/Tunneling Document location and depthDocument location and depth Use hands of clock as descriptorUse hands of clock as descriptor Measure with cotton tipped Measure with cotton tipped
applicatorapplicator
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Staging LimitationsStaging Limitations
Difficult to identify stage I in dark Difficult to identify stage I in dark skinned patientsskinned patients
Unable to stage when obscured by Unable to stage when obscured by eschareschar
Reverse Staging/DownstagingReverse Staging/Downstaging
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Nursing ProcessNursing ProcessDiagnosisDiagnosis
You tell me!!!!!You tell me!!!!!
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Nursing ProcessNursing ProcessPlanningPlanning
Preventing pressure ulcers-early Preventing pressure ulcers-early identification of those at risk (Braden, identification of those at risk (Braden, Norton, Gosnell scales)Norton, Gosnell scales)
Prevention protocols by hospitalPrevention protocols by hospital PositioningPositioning Hygiene and skin care (incontinence care)Hygiene and skin care (incontinence care) Support surfacesSupport surfaces Nutritional supportNutritional support Prevent friction and shearPrevent friction and shear EducationEducation
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Nursing ProcessNursing ProcessAcute Care ImplementationAcute Care Implementation
Management of Pressure UlcersManagement of Pressure Ulcers Culturing woundCulturing wound Cleansing woundCleansing wound Debridment of woundDebridment of wound Moist Wound HealingMoist Wound Healing Dressing selectionDressing selection Nutritional supportNutritional support Off-load pressureOff-load pressure
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Wound Dressing Wound Dressing SelectionSelection
Goal: Promote moist wound healingGoal: Promote moist wound healing Transparent dressingTransparent dressing HydrocolloidHydrocolloid HydrogelHydrogel Calcium alginateCalcium alginate Foam dressingFoam dressing Silver/AntimicrobialSilver/Antimicrobial Collagen dressingCollagen dressing Biological dressing (Regranex)Biological dressing (Regranex) Negative pressure wound therapy (VAC)Negative pressure wound therapy (VAC)
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Practice ScenarioPractice Scenario The nurse is assessing a bedridden client The nurse is assessing a bedridden client
when a large erythemic area is noted on when a large erythemic area is noted on the client’s sacrum. In addition, the the client’s sacrum. In addition, the center of the injury looks like an center of the injury looks like an abrasion with a shallow center. The abrasion with a shallow center. The nurse would classify this ulcer as:nurse would classify this ulcer as:
How will the nurse treat this type of How will the nurse treat this type of pressure ulcer?pressure ulcer?
What risk factors could have contributed What risk factors could have contributed to this patient developing a pressure to this patient developing a pressure ulcer?ulcer?
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Practice QuestionPractice Question
A nurse is working in a geriatric A nurse is working in a geriatric screening clinic. The nurse would expect screening clinic. The nurse would expect that the skin of the normal elderly client that the skin of the normal elderly client will demonstrate which of the following will demonstrate which of the following characteristics?characteristics?
A. Dehydration causing skin to swell.A. Dehydration causing skin to swell. B. Moist skin turgor.B. Moist skin turgor. C. Skin turgor showing a loss of elasticityC. Skin turgor showing a loss of elasticity D. Overhydration causing skin to wrinkle.D. Overhydration causing skin to wrinkle.
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Practice QuestionPractice Question
The nurse decides to treat a Stage II The nurse decides to treat a Stage II pressure ulcer with a hydrocolloid pressure ulcer with a hydrocolloid dressing. The nurse recognizes that dressing. The nurse recognizes that the dressing will promote which type the dressing will promote which type of wound debridement?of wound debridement?
A. Sharp A. Sharp B. Autolytic B. Autolytic C. ChemicalC. Chemical D. MechanicalD. Mechanical