-
Skin Integrity
Explain the nurse interventions for a stage 1 pressure ulcer
- ⇨Frequent turning
- ⇨Keep pressure off
- ⇨special mattress
- ⇨frequent inspection
- ⇨pressure relieving devices
-
Skin Integrity
Explain the nurse interventions for a stage 2 pressure ulcer
- ⇨Moist healing dressings (sometimes honey)
- ⇨bandage cleaned regularly
- ⇨sterile
-
Skin Integrity
Explain the nurse interventions of a stage 3 pressure ulcer
- ⇨Proteolytic enzymes (form of debridement that eats away dead tissue, doctor order is required)
- ⇨requires debridement
- ⇨surgical procedure may be necessary (by doctor)
-
Skin Integrity
Explain the nurse interventions for a stage 4 pressure ulcer
- ⇨pack with iodine goze (it's sterile)
- ⇨Skin graphing
-
Skin Integrity
Describe the characteristics of a stage 1 ulcer
- ⇨Intact skin
- ⇨Nonblanchable erythema
- ⇨if the redness goes way it is not a stage one
-
Skin Integrity
Describe the characteristics of a stage 2 ulcer
- ⇨Partial thickness skin loss in epidermis and or dermis
- ⇨superficial
- ⇨clinically described as abrasion, blister or shallow crater
-
Skin Integrity
Describe the characteristic of a stage 3 pressure ulcer
- ⇨Full thickness skin loss
- ⇨damage or necrosis of subcutaneous tissue
- ⇨extends down (but not through) underlying fascia.
- ⇨clinically as deep crater w/or w/out undermining of adjacent tissue
-
Skin Integrity
Describe the characteristics of a stage 4 pressure ulcer
- ⇨Full thickness skin loss w/ extensive destruction
- ⇨Damage to muscle, bone, tissue necrosis, and nay supporting structures
- ⇨sinus tracts and undermining.
-
Skin Integrity
Limitations?
- ⇨Difficult to determine on dark skin (stage 1)
- ⇨eschar (dark skin) may need to be debrided because it's hard to determine the stage.
-
Skin Integrity
Is reverse staging possible?
No
-
Skin Integrity
Recommendations for those clients determined to be at risk
- Skin Inspection⇨At least daily
- ⇨check bony places
- ⇨document any findingsProtecting Skin
- ⇨Clean patients up quickly after every incident
- ⇨Avoid hot water use
- ⇨Use lotion
- Positioning
- ⇨Avoid friction
- ⇨careful with transfers
- ⇨special pads for wheel chairs, or mattress
- Nutrition⇨supplements
- ⇨fluids
-
Skin Integrity
Recommendations for those clients determined to be at risk: Documentation, care planning, bed bond, chair bound
- Documentation
- ⇨every time you turn
- ⇨any wounds found
- Care Plan
- ⇨Norton scale
- Bed Bound
- ⇨repositioning
- ⇨Use pillows
- ⇨Try and keep heals off bed
- ⇨lift devices
- Chair Bound
- ⇨Reposition/hr
- ⇨shift weight
|
|
