Transcript PN 124 Day 5, Venous and Pressure ulcers

Integumentary System, PN 124
 Causes
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- chronic deep vein insufficiency
- delay of venous blood returning to the
central circulation
-severe varicose veins, burns, trauma,
sickle cell anemia, diabetes, neurogenic
disorders and heredity
-Dry/rough looking skin
 -Hard to the touch
 -Loss of body hair
 -Ulcers begin as small, tender, inflamed
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-Edema around the ulcer
 -Occasional purulent drainage
 -Slow to heal
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 Subjective
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Data
-Severity of ulcer pain
-worse with the leg dependent
-itching
-duration
-measures to treat the ulcer
 Objective
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Data-
-Size
-location
-appearance
-Color
-both in a dependent and elevated
position
-Wound drainage
-color and consistency
-edema
-Surrounding skin appearance
-erythema, induration
 Limb
elevation
-encourages return of venous blood to the
general circulation
-increases arterial blood flow
-to general circulation and lower extremities
-decreased edema.
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Compression dressings
-Unna Boot
 Infection
Control
-aseptic technique with dressing changes
-monitor for signs of infection
-cellulitis
 Antibiotics-topical (Silvadine cream)
-oral or IV
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 Debridement
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-Removal of necrotic tissue
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- Mechanical
-wet to dry dressings
-Chemical
- Enzyme (Santyl, Elase)
-Surgical
-used only if mechanical and chemical
means were ineffective
-removal via scalpel of necrotic tissue
 Dressings
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-Compression
-Unna boot, Ace bandages, TED socks
 Pain
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Management
-Elevate legs, analgesics, topical
anesthetics
Nutrition
-Protein, Vitamin A, Vitamin c, Zinc
(Bedsores/decubitus ulcers)
Causes
-Pressure on the skin
-collapse of capillaries
-ischemia/redness-1 hour
-tissue necrosis-after 2 hours
-boney prominences
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 Shearing
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-Force exerted against the skin
-movement or repositioning
-Stretches and tears the blood vessels,
-reducing blood flow
-necrosis develops
 Friction
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_the force of 2 surfaces moving across on
another
_the rubbing of skin against the sheets
_removes superficial skin
_increases the risk of skin breakdown
Moisture
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- incontinence urine and feces
-wound drainage
-perspiration
 Stage
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I
- Non-blanchable erythema of intact skin
 Stage
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II Pressure ulcer
-Partial thickness skin loss
-epidermis, dermis or both.
-Ulcer is superficial
-abrasion, blister or shallow crater
 Stage
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III Ulcer
-Full thickness skin loss
-damage or necrosis to the subcutaneous
tissue.
-May extend down to, but not through the
underlying fascia.
-Deep crater with/without undermining of
the adjacent tissue.
 Stage
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IV Ulcer
-Full thickness skin loss
-extensive bone destruction, tissue
necrosis, or damage to muscle, bone, or
supporting structures
-Undermining and sinus tracts
 Surrounding
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skin
-intact edges
-erosion
-maceration
-erythema
-edema
 Braden
Assessment Tool
 Norton
Pressure Ulcer Scale
 Norton
Assessment Tool
Risk
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factors for pressure ulcers
Impaired mobility
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-bedbound
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-wheelchair bound
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-dependent on positioning
 2. Moisture
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-incontinent of urine and/or feces,
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-perspiration
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-wound drainage
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3. Nutritionally compromised
-underweight
-obese
-poor nutritional status
-poor food/fluid intake
-secondary to poor appetite
-dysphasia
-limited ability to feed themselves.
4. Disease Process
-diabetes
-anemia
-atherosclerosis,
-edema
5. Vitamin and Mineral Deficiencies
-vitamin A, C, E, Zinc
 Identify
the at-risk patient
 -elderly
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-impaired mobility
-poor nutritional status
-altered level of consciousness
Pressure
relieve
 -written repositioning/ turning
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schedule
-30 degree position when side lying
-pillows and foam wedges
-turn sheet to reposition or lift patient
in the bed
-encourage patients in wheelchairs to
shift their weight every 15 minutes
 Cleansing
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of the skin
-inspect the skin daily
-mild cleanser for bathing
-avoid massaging skin over a boney
prominence
-moisturizer on the skin
-protective barrier ointment for incontinent
patients
-clean the skin at the time of incontinence.
 Pressure
cushions
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relieving mattress and
-Egg carton mattress
-Geomatt mattress
-foam overlay mattress
-comparatively inexpensive
-Air overlay mattress
-placed over the hospital bed mattress
-weight redistribution
-Clinitron Bed
-mattress filled with small glass sand particles,
-moisture flows through the mattress
 KCI/Kin
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Air Bed
-mattress of air-inflated pillows divided into
sections
-pressure can be adjusted in each of the
sections according to the client’s needs
-air flow form the mattress to eliminate
moisture.
PREVENTION!!!
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-most important aspect to be taught to
client’s and their caregivers!!
 1. Turning, positioning and shifting
-every 2-3 hours- even during the night.
 2. Observe skin daily
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3. Diet adequate in protein, vitamins, calories
and good fluid intake.
 4. Notify the health care provider for any
changes in the skin.
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 -After
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a pressure ulcer has appeared
-Reinforce aggressive turning, positioning
and pressure relief.
-Home Health RN
-assess the wound
-instruct the client and/or caregiver
-wound care
-signs of healing vs. deterioration
-homebound clients