Contributing factors

Contributing factors 150 150 Tony Guo

Contributing factors

  • Amount of pressure (intensity)
  • Length of time pressure is exerted (duration)
  • Ability of tissue to tolerate externally applied pressure
  • Shearing force: Pressure exerted on skin when it adheres to bed and skin layers slide in direction of body movement
  • Moisture:  Excessive increases risk for skin breakdown

 

Types of ulcers stages/categories

  1. Nonblanchable erythema
  • Intact skin with nonblanchable redness of a localized area usually over a bony prominence
  • The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue
  1. Partial thickness
  • Loss of dermis 
  • Shallow open ulcer with a red-pink wound bed, without slough (looks like a serosanguinous- filled blister)
  1. Full-thickness skin loss
  • Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed
  • Include undermining and tunneling
  • Depth ulcer varies by location
  1. Full-thickness tissue loss
  • Exposed bone, tendon, or muscle that are visible or directly palpable, and includes undermining and tunneling
  • Can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis or osteitis likely to occur

Other stages

  • Suspected deep tissue injury
    • Unknown depth
    • Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
    • May be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.

Clinical manifestation

  • Signs
  • Leukocytosis
  • Fever
  • Increased ulcer size, odor, or drainage
  • Necrotic tissue
  • Indurated, warm, painful

Complications

  • Most common and keeps recurring
  • Cellulitis
  • Chronic infection
  • Osteomyelitis
  • Possible death

 

Nursing Implementation

  • Health promotion
    • Prevention is the best treatment for pressure ulcers
      • Identification of patients at risk for developing pressure ulcers 
      • Implementation of pressure ulcer prevention strategies for those who are at risk.
      • Teach the patient about the etiology of pressure ulcers, prevention techniques, early signs, nutritional support, and care techniques for actual pressure ulcers.
    • Remove excessive moisture
    • Avoid massage over bony prominences
    • Use lift sheets
    • Skin care
      • Position with pillows or elbow and heel protectors
      • Use specialty beds
      • Cleanse skin if incontinence occurs
  • Use pads or briefs that are absorbent
  • Ulcer care
    • Document and describe stage, size, location, exudate, infection, pain, and tissue appearance
      • Measure length and width
      • Measure depth
    • Relieve pressure
    • Debride
    • Cleanse with nontoxic solutions
    • 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
  • Acute care
    • Care of a patient with a pressure ulcer requires local care of the wound and support measures of the whole person, like:- 
      • Adequate nutrition
      • Pain management
      • Control of other medical conditions
      • Pressure relief
    • Initiate interventions based on the ulcer characteristics (e.g., stage, size, location, amount of exudate, type of wound, presence of infection or pain) and the patient’s general status (e.g., nutritional state, age, cardiovascular status, level of mobility).
    • Carefully document the size of the pressure ulcer
      • Wound-measuring card or tape (length and width)
      • Sterile cotton-tipped applicator (depth)

Evaluation

  • Healing of pressure ulcer
  • Intact skin with no further breakdown

 

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