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Related Flashcards
Related Topics
Cards In This Set
| Front | Back |
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Skin: major functions
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1. protect underlying tissue
2. body temp regulation 3. first line defense against infection 4. nerve receptors to indicate pain, hot, cold, pressure |
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Skin Breakdown: Risk factors
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-thin or obese
-poor nutrition -immobility -assistive devices- causes friction -pain meds- decrease sensation and less mobile -increased age -impaired circulation -bony prominences |
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Shearing Forces
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-happens when you raise the HOB and the pt's body slides down the bed
-the skin on the coccyx rolls up and is in an abnormal position and causes a pressure sore |
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Skin Breakdown: Contributing factors
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Moisture- perspiration, incontinence
friction- transferring, sliding board, etc. Malnutrition, dehydration- older adults decreased muscle mass anemia |
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Screening tools
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Braden Scale- most widely used
- highly reliable and valid - measures many patient risk factors Norton Scale- less in depth - measures- pt activity, mental status, mobility, general physical condition, and incontinence |
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Skin Breakdown: Prevention
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-MOST IMPORTANT
- keep clean- use soap and water, minimize friction - avoid dryness- leads to cracking - do not massage red spots or bony prominences - check serum albumin levels (3.2 - 4.5) |
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Prevention Con't
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- encourage activity- moving, getting up to chair
- document and monitor interventions and outcomes- use screening tools - Implement pressure relief- turning as pt needs, special bed, air mattress |
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Pressure Relief
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-assess whether you're providing relief
-put your hand underneath the cushion and feel for the pt's weight on your hand |
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PUSH
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Pressure Ulcer Scale for Healing
-helps in documenting a wound -considers: size, drainage, and tissue type |
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Pressure Ulcer: stage 1
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Nonblanchable
skin intact redness DOES NOT go away- even when change positions |
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Pressure Ulcer: stage 2
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Partial thickness loss of the dermis
-Will see: an abrasion, blister, or a shallow crater |
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Pressure Ulcer: stage 3
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Full-thickness loss of the dermis
SubQ tissue may be visible there could be tunneling |
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Pressure Ulcer: Stage 4
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Damage to muscle and bone
necrosis slough- yellow, fibrous gunk in wound tunneling |
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Closed Black Wound
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Chart as "a closed black wound"
CANNOT stage it- b/c you can't see inside the wound often go to whirlpool to increase circulation to area |
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Treatment: stage 1
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- Cleanse with NS
- pressure relief- heel and elbow protectors - clear dressing- thin Duoderm (protect and visualize it) |
