Skin:Pressure Ulcers
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| Pressure Ulcer | Tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period
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| Tissue Compression | Restrict blood flow to the skin, resulting in tissue anoxia and cell death; common in people with limited mobility because they are unable to change their position to relieve pressure
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| Pressure | Determined by the amount of weight exerted at the point of contact, the distribution of weight at the point of contact, and the density of the contacting surface; excessive or prolonged pressure can compress blood vessels causing ischemia, tissue necrosis
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| Friction | Occurs when surfaces rub the skin and irritate or directlly pull off epithelial tissue; Generated when the client is dragged or pulled across bed linen
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| Shear | Generated when the skin itself is stationary and the tissues below the skin (fat or muscle) shift or move
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| Pressure Ulcer Prevention Program | 1.Identification of high-risk clients2.Implementation of aggressive intervention for prevention with the use of pressure relief or reduction devices
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| Mental Status/Decreased Sensory Perception | Understanding that turning and shifting of weight prevent tissue damage, the risk for pressure ulcers decreases.Stroke, head injury, organic brain disease, Alzheimer's disease, or other problem with cognition, the risk for pressure ulcer formation go up
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| Activity/Mobility | The level of the client's independent mobility is a direct factor in the risk for pressure ulcer formation; Any client who requires assistance with turning and positioning or who is less aware of physical sensation change is at high risk for ulcer.
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| Nutritional Status | Intact skin and wound healing are dependent on a positive nitrogen balance and adequate serum protein levels; Client in a negative nitrogen balance not only heals more slowly but also is at greater risk for tissue destruction;Draining wounds protein lost
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| Incontinence | Results in prolonged contact of the skin with urea, bacteria, yeast, and enzymes carried in urine and feces, these irritants lead to skin breakdown. REDDENED AREAS ARE NEVER MASSAGED BECAUSE THIS ACTION CAN DAMAGE CAPILLARY BEDS AND INCREASE TISSUE DEATH
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| Pressure-Relieving Techniques | Cornerstone in the prevention of pressure is adequate pressure relief.
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| Capillary Closing Pressure | The amount of pressure needed to occlude skin capillary blood flow in the area at risk; Observe skin color, integrity, and temperature to determine capillary flow adequacy.
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| "Bottoming Out" | The client's bony prominences sink into the mattress or cushion, causing him or her to have pressure even with the product in place
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| Pressure Relieving Devices-Used along with a turning schedule | 1.Prevention of skin breakdown because they cannot turn2.Prevention of extension of skin breakdown that has already occurred3.Promotion of healing or breakdown present on several turning surfacees
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| Positioning-30 degree Rule | Ensures that the client is positioned and propped so that whatever part of the body is elevated is tilted back at least 30 degrees to the mattress rather han resting directly on a dependent bony prominence.
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| Positioning2 | The client who must be elevated to a full 90 degrees because of respiratory difficulties should be tilted forward even more than 90 degrees, with pillows behind the back to keep pressure off sacral/coccyx; Client is also at risk while sitting
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| Turning | Turning and positioning every 2 hours; However, pressure can occur in less time, and the actual turning or repositioning schedule for each client must be individualized.
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| Wound Assessment | Assess the wound as a clock face with 12 o'clock in the direction of the client's head and 6 o'clock in the direction of the client's feet; measure depth as the distance from the deepest portion of the wound base to the skin level
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| Eschar | A layer of black, gray, or brown nonviable, denatured collagen; dry, leathery, and firmly attached to the wound surface in early stages.
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| Contamination | Presence of organisms without any clinical manifestation of infection.*A wound that is exposed is ALWAYS CONTAMINATED but NOT always INFECTED.
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| Wound Infection | Contamination with pathogenic organisms to the degree that growth and spread cannot be controlled by the body's immune defense.
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| Pus | The presence of pus as exudated alone does not indicate an infection because pus formation occurs when necrotic tissue debrides and liquefies.
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| Undermining | Separation of the skin layers at the wound margins from the underlying granulation tissue
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| Drug Therapy | Clean, healthy granulation tissue has a blood supply and is capable of providing white blood cells and antibodies to combat infection;In the absence of infection, antibiotics are avoided because of danger of the development of resistant strains of bacteri
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| Diet Therapy | Encourage the client to eat a well-balanced diet, emphasizing foods containing nutrients vital to cell growth and collagen synthesis; if client cannot eat sufficiently, NG feedings and hyperalimentation via central venous catheter
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| Electrical Stimulation | Applying a low-voltage current to a wound arean can increase blood vessel growth and promote granulation; Not used with clients who have a pacemaker or who have a wound over the heart
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| Vacuum-Assisted Wound Closure | Enhances the formation of granulation tissue; suction covered by a special sponge and sealed in place for 48 hours; continuous low-level negative pressure is applied through the suction tube
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| Hyperbaric Oxygen Therapy | Administration of oxygen under high pressure, raising the tissue oxygen concentration; Systemic oxygen enhances the ability of white blood cells to kill bacteria and reduce swelling.
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| Debridement | Sharp excision of thick, adherent wound eschar using a scapel or scissors
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| Grafting | Used for wound closure when full-thickness ulcers are unable to close and when natural healing would result in loss of joint function, an unacceptable cosmetic appearance, or a high potential for wound recurrence.
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| Report the following signs to the PHYSICIAN | 1.Sudden deterioration of the ulcer as evidenced by an increase in size or depth of the lesion2.Changes in the color or texture of the granulation tissue3.Changes in the quantity,color, or odor of exudate
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| Classic Signs of Wound Infection | Increased redness, edema, purulent and malodorous drainage, and tenderness of the wounds, elevated white blood cell count and positive blood cultures
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