Download Pressure Ulcers

Zoya Minasyan, RN, MSN-Edu
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A localized injury to the skin and/or
underlying tissue due to pressure with or
without shear/friction
Most common sites
▪ Sacrum
▪ Heels
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Advanced age
Anemia
Contractures
Diabetes mellitus
Elevated body temperature
Immobility
Impaired circulation
Incontinence
Low diastolic blood pressure
(<60 mm Hg)
Mental deterioration Neurologic disorders
Obesity
Pain
Prolonged surgery
Vascular disease
•Ulcers are graded or staged according to
deepest level of tissue damage
• A pressure ulcer may also present as a blood-filled blister.
• Stable (dry, adherent, intact) eschar on the heels serves as “the body’s natural
(biologic) cover” and should not be removed.
Intact skin with non-blanchable
redness
Possible indicators—Skin temperature,
tissue consistency, pain
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May appear with red,
blue, or purple hues in
darker skin tones
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Partial-thickness loss of dermis
Shallow open ulcer with red pink wound bed
Presents as an intact or ruptured serum-filled
blister
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Full-thickness skin loss
involving damage or
necrosis of subcutaneous
tissue that may extend
down to, but not through,
underlying fascia
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Presents as a deep crater
with possible undermining
of adjacent tissue
Depth of ulcer varies by
anatomic location.
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Full-thickness loss can
extend to muscle, bone,
or supporting structures.
 Bone, tendon, or muscle
may be visible or palpable.
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Undermining and
tunneling may also
occur.
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Signs of infection
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Leukocytosis
Fever
Increased ulcer size, odor, or drainage
Necrotic tissue
PainMost common complications
 Recurrence
 Cellulitis (is a inflammation of connective tissue with
severe inflammation of dermal and subcutaneous
layers of the skin)
 Chronic infection
 Osteomyelitis (an infection of the bone or bone
marrow)
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Assess pressure ulcer risk on admission and at periodic
intervals based on care setting and patient’s condition.
Use risk assessment tools such as the Braden scale for
systematic skin inspection.
Look for areas of skin darker (purplish, brownish, bluish)
than surrounding skin.
Use natural or halogen light for accurate assessment
(fluorescent light casts a blue color that can skew results).
Assess skin temperature using your hand.
An ulceration may feel warm initially, then become cooler.
Touch the skin to feel its consistency.
 Boggy or edematous tissue may indicate a stage I pressure
ulcer.
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Ask about pain or an itchy sensation.
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Overall goals
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No deterioration
Reduce contributing factors
Not develop an infection
Healing and no recurrence
Prevention is the best treatment.
 Identify risk factors and implement prevention strategies.
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Remove excessive moisture.
Avoid massage over bony prominences.
Turn every 1 or 2 hours (with care to avoid shearing).
Use lift sheets.
Position with pillows or elbow and heel protectors.
Use specialty beds.
Cleanse skin if incontinence occurs.
 Use pads or briefs that are absorbent.
Caloric intake elevated to
30 to 35 cal/kg/day or
1.25 to 1.50 g protein/kg/day
 Supplements, enteral, or parenteral feedings may be necessary.
Document and describe size, stage, location,
exudate, infection, pain, and tissue appearance.
 Keep ulcer bed moist.
 Cleanse with nontoxic solutions.
 Debride.
 Use adhesive membrane, ointment, or wound
dressing.
 Verify good nutrition.
 Teach self-care and signs of breakdown.
 Initiate specialty services.
 Skin grafts
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Microscopic view of the skin in longitudinal section.
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Structures
 Epidermis
 Dermis
 Subcutaneous tissue
Irregular pigmentation and keratoses occur on sun-damaged skin on forehead.
Normal Physical Assessment of Integumentary System.
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Subjective Data
 Important health information
▪ Past health history
▪ Medications
▪ Surgery or other treatments
 Functional health patterns
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Health perception–health management pattern
Nutritional-metabolic pattern
Elimination pattern
Activity-exercise pattern
Sleep-rest pattern
Cognitive-perceptual pattern
Self-perception–self-concept pattern
Role-relationship pattern
Sexuality-reproductive pattern
Coping–stress tolerance pattern
Value-belief pattern
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Objective Data: Physical examination-Inspection,
Palpation
Intertrigo. Rash in body folds with Candida infection.
Vitiligo. Total loss of pigment in the affected area.
Naevus of Ota. Flat gray to blue pigmentation in the upper trigeminal area, which is more
common in dark-skinned individuals.
Traction alopecia. Hair loss in scalp due to prolonged tension from hair rollers and braiding and
straightening combs.
Basal cell carcinoma. Rolled, well-defined border and central erosion.
Squamous cell carcinoma of the finger.
Breslow measurement of tumor thickness. A, Thin (0.08° mm) superficial spreading melanoma
good prognosis. B, Thick nodular melanoma with lymph node involvement, poor prognosis.
Dysplastic nevus. Irregular border and color.
Herpes zoster (shingles) on the anterior chest, confined to one dermatome.
Plantar wart. A, Keratotic lesion. B, After excision.
Candidiasis in interdigital cleft. Occurs in workers whose constantly wet hands are not dried often.
Tinea unguium (onychomycosis). Fungal infection of toenails. Crumbly, discolored, and
thickened nails.
Scabies infestation on hand.
Psoriasis. Characteristic inflammation and scaling.
Acne vulgaris. Papules and pustules.
Seborrheic keratoses. Deeply pigmented, rough and warty surface.
Fig. 24-17. Curettage. The superficial growth is removed by a gentle scoping technique.
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Collaborative Therapy, continued
 Drug therapy
▪ Antibiotics
▪ Corticosteroids
▪ Antihistamines
▪ Topical fluorouracil
▪ Immunomodulators
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Diagnostic and Surgical Therapy
 Skin scraping
 Electrodesiccation and electrocoagulation
 Curettage
 Radiation therapy
 Laser technology
 Cryosurgery
Punch biopsy. A, Removal of skin for diagnostic purposes. B, Specimen obtained.
A, Removal of melanoma by Mohs, surgery. B, Following plastic surgery using a skin flap to
repair defect.
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Ambulatory and Home Care
 Wet dressings
 Baths
 Topical medications
 Control of pruritus
 Prevention of spread
Face-lift. A, Preoperative. B, Postoperative.
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Elective Surgery
 Laser surgery
 Face lift
 Liposuction