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What are 4 factors that contribute to pressure ulcers?
- Mobility and Activity
- Sensation
- Intrinsic Factors
- Extrinsic Factors
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What are intrinsic factors that contribute to pressure ulcers?
- Nutrition
- Age
- Circulation
- Underlying health status
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What extrinsic factors that contribute to pressure ulcers?
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What do mobility and activity and sensation specifically contribute to?
Time and pressure
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What do intrinsic and extrinsic factors contribute to?
Tissue tolerance
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What are characteristics of a stage 1 pressure ulcer?
- nonblanchable
- epidermis involved.
- Could be coccyx, heels.
- Tissue is swollen and congested
- blood supply is cut off
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What are the characteristics of a stage 2 pressure ulcer?
- partial thickness loss
- open and shallow
- pink or red wound bed
- looks like an abrasion.
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What are the characteristics of a stage 3 pressure ulcer?
- deeper
- full thickness loss,
- necrosis of subQ layer
- extends but not through fascia.
- Undermining (pockets off to side) might be present
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What are characteristics of a stage 4 pressure ulcer?
- full thickness
- through fascia
- sometimes might see bone. Rare but happens.
- Tissue necrosis.
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What does the number on the Braden score signify?
The lower the score, the greater the risk someone is at for a pressure ulcer.
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What are the SIX categories we assess in the Braden scale?
- Sensory Perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction & Shear
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How do we begin to prevent pressure ulcers?
Create patient-centered goals
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What is the nursing diagnosis associated with pressure ulcers?
Impaired skin integrity related to shearing/friction...
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What is an integral part of the pressure ulcer planning process?
Education
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What are SIX nursing interventions related to pressure ulcers?
- Prevention
- Meticulous skin care and moisture control
- Adequate nutrition
- Frequent repositioning
- Therapeutic mattresses
- Client/family teaching
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How do you evaluate if the pressure ulcer is healing?
- Physical signs of healing and the status of the pressure ulcer
- Client’s adaptation to the altered skin integrity
- Each intervention should be evaluated for its effectiveness.
- Plan of care is revised to reflect most beneficial actions.
- PUSH Tool-Pressure Ulcer Scale for Healing
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What are SIX types of OPEN wounds?
- Incision
- Laceration
- Abrasion
- Puncture
- Penetration
- Gunshot
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What are THREE types of closed wounds?
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How do we classify wounds by age?
acute and chronic
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How would you describe acute wounds?
- New
- Healing
- Disruption in tissue
- Approximated-can push edges back together
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How would you describe chronic wounds?
- Not healing
- Ulcers
- Unapproximated
- Complications
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How do you classify a wound by it depth?
- Superficial-epidermis
- Partial-epidermis and superficial dermis
- Full-gone through several layers
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What are the THREE color classifications of a wound?
- Red=blood flow
- Yellow=caution, like a stoplight.Could mean healing or could mean slough or infection
- Black-needs to be debridement, enzymatic cream. Dead tissue. Needs to be gotten rid of.
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What are factors that affect wound healing?
- Nutrition
- Oxygenation
- Infection
- Age
- Chronic health condition
- Medications
- Smoking
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What are some signs of a complicated healing wound?
- Hemorrhage
- Infection
- Dehiscence
- Evisceration-pop open and have protrusion of organs
- Fistula formation-will appear as tunneling
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What are FOUR ways to describe wound drainage?
- Serous-straw colored fluid, yellowish, usually clear
- Sanguineous-straight blood
- Serosanguineous-combo of the two
- Purulent-thick, yellow, odor
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What do we look for when assessing the wound bed?
- Wound dimensions (size and depth)
- Tunneling and undermining
- Bed texture
- Bed moisture
- Wound odor
- Margins and surrounding skin
- Pain?
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When documenting a wound, what does W.O.U.N.D. stand for?
- Wound/ulcer location
- Odor
- Ulcer category, stage, classification, depth
- Necrotic tissue
- Dimension and drainage
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When documenting a wound, what does P.I.C.T.U.R.E. stand for?
- Pain
- Induration
- Color of wound bed
- Tunneling
- Undermining
- Redness
- Edges
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What nursing diagnoses do I need to remember in regards to wounds?
- Impaired Tissue Integrity
- Risk for Infection
- Pain
- Disturbed Body Image
- DeficientKnowledge (wound care)
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What are priorities for patient outcome and planning?
- Client’s identified needs
- Individualized
- Promoting wound healing
- Preventing infection
- Education
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What should we never use when cleaning a wound?
Never use: Perioxide, Betadine or Dakin’s solution
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What should we use when cleaning a wound?
Normal saline or commercial noncytoxic solution
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What is the optimal pressure to use when cleaning a wound with irrigation?
8#/sq in of pressure.
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What are FIVE different ways to debride a wound?
- Sharp
- Mechanical
- Chemical
- Enzymatic
- Autolysis
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