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A break in the skin or mucous membrane.
- A wound. Good skin care is needed to prevent wounds. Wounds are portals of entry for microbes.
- A break or rip in the skin. The epidermis (top skin layer) separates from the underlying tissues.
- A skin tear. The hands, arms, and lower legs are common sites for skin tears.
- Skin tears are caused by friction and shearing, pulling, or pressure on the skin.
- Skin tears are painful. Tell the nurse at once if you cause or find a skin tear. To prevent skin tears:
- - Keep your fingernails short and smoothly filed.
- - Keep the persons fingernails short and smoothly filed. Report long and tough toenails to the nuse.
- - Do not wear bracelets.
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Any injury caused by unrelieved pressure. It usually occurs over a bony area - shoulder blades, elbows, hips, sacrum, knees, ankles, heels, and toes.
A pressure ulcer (decubitus ulcer, bedsore, pressure sore)
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Pressure, friction, and shearing are common causes of skin breakdown and pressure ulcers. Other factors include breaks in the skin, poor circulation to an area, moisture, dry skin, and irritation by urine and feces. Older and disabled persons are at great risk for pressure ulcers. Causes include age-related changes, chronic disease, and general debility.
Pressure occurs when the skin over a bony area is squeezed between hard surfaces. The bone is one hard surface. Squeezed between hard surfaces. The bone is one hard surface. The other is usually the mattress or chair seat. Squeezing or pressure prevents blood flow to the skin and underlying tissues. Lack of blood flow means oxygen adn nutrients cannot get to the cells. Therefore involved skin and tissues die.
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The rubbing of one surface against another.
Friction. Friction scrapes the skin, causing an open area.
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When the skin sticks to a surface while muscles slide in the direction the body is moving. This occurs when the person slides down in the bed or chair. Blood vessels and tissues are damaged. Blood flow to the area is reduced.
Shearing
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Persons at risk for pressure ulcers are those who:
- Are confined to bed or chair
- Need some or total help in moving.
- Have loss of bowel or bladder control
- Have poor nutrition or fluid balance
- Have altered mental awareness
- Have problems sensing pain or pressure
- Have circulatory problems
- Are older, obese, or very thin
Pressure ulcers occur over bony areas. The bony areas are called pressure points.
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The first sign of a pressure ulcer is pale skin or a redened area. The person may complain of pain, burning, or tingling in the area.
- Stages of Pressure Ulcers:
- Stage 1: The skin is red. The color does not return to normal when the skin is relieved of pressure. The
- is intact.
- Stage 2: The skin cracks, blisters, or peels. There may be a shallow crater.
- Stage 3: The skin is gone. The exposed tissue is damaged. There may be drainage form the are.
- Stage 4: Muscle and bone are exposed and damaged. Drainage is likely.
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Prevention and Treatment
- Good nursing care, cleanliness, and skin care are essential.
- Ther person at risk ror pressue ulcers is place on a surface that reduces or relieves pressure. Such
surfaces include foam, air, alternationg air, gel, or water mattresses.
- - The person is repositioned at least every 2 hours. Some persons are repositioned every 15 minutes.
- - The 30-degree lateral position is recommended.
- - Prevent shearing. Do not raise the head of the bed more than 30 degrees.
- - Minimize skin exposure to moisture. Check incontinent person often. Also check persons who perspire
- heavily and those with wound drainage.
- - Check with the nurse before using soap. Soap can dry and irritate the skin.
- - Apply a moisturizer to dry areas such as the hands elbows, legs ankles, and heels. The nurse tell you
- what to use and the areas that need attention.
- - Give a back massage when repositioning the person. Do not massage bony areas.
- - Keep linens clean, dry, adn free of wrinkles.
- - Apply powder where skin touches skn.
- - Never rub or massage reddened areas.
- - Remind persons sitting in chairs to shift their positoin every 15 minutes.
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Placed on the bed. Top linens are brought over the cradle to prevent pressure on the legs and feet.
Bed cradle
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Fit the shape of the elbow.
Elbow protectors
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Pillows or special cushion are used to raise the heels off the bed. Special braces adn splint also are use to keep pressure off the heel.
Heel elevators
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Are made of a gel-like substance. the outer case is heavy plastic.
Flotaton pads or cushions
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A foam pad that looks like an egg carton. Peaks in the mattress distribute the peson's wight more evenly.
- Eggcrate-like mattress.
- + Trochanter rolls adn footboards are also used.
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Some people ahve diseases that affect blood flow to and from the legs and feet. Such poor circulation can lead to pain, open wounds, and swelling of tissues (edema). Infection and gangrene can result form the open wound and poor circulation.
- Measures to Prevent Circulatory Ulcers
- - Remind the person not to sit with the legs crossed.
- - Do not dress the person in tight clothes.
- - Do not scrub or rub the skn during bathing and drying.
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A condition in which there is death of tissue.
Gangrene
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Open wounds on the lower legs and feet caused by decreased blood flow through arteries or veins.
Circulatory ulcers (vascular ulcers). Persons with diseases affection the blood vessels ar at risk.
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Open wounds on the lower legs and feet caused by poor blood return through the veins. The heels and inner aspect of the ankles are common sites. They can occur form skin injury. Scratching is a common cause.
Stasis ulcers (venous ulsers)
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Open wound on the lower legs and feet caused by poor arterial blood flow. They are found between the toes, adn on the outer side of the ankle. The heels are common sits for persons on bedrest. These ulcers can occur from shoes that fit poorly.
Arterial Ulcers
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The doctor order elastic stockings to promote circulation.
Elastic stockings are often ordered for person with circulatory disorders. They also are ordered for persons on bedrest. People on bedrest are at risk for develping blood cloth (thrombi). A blood clot is called a thrombus.
- The elastic exerts pressure on the veins. The pressure promotes venous blood flow to the heart. The stockings also are called anti-embolism or anti-embolic (AE) stockings.
- Stockings are applied before the person gets out of bed.
- They are removed every 8 hours for 30 minutes or according to the care plan. The person lies in bed while they are off. This prevents the legs from swelling.
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