Pressure ulcer risk factors
Shear: skin sliding across skeleton
Friction: skin against sheets
Impaired mobility
Altered LOC
Moisture: incontinence
Impaired sensory perception
Nutrition: malnourished
Pressure Ulcer Documentation
Location
Stage
Size (length, width, depth): Cotton tipped applicator.
Sinus tract or tunneling
Undermining: ridge/gap
Necrotic tissue; eschar
Slough or drainage: thick yellow film covering wound
Granulation: healthy tissue (red, moist tissue)
Surrounding
Stage I pressure ulcer
Nonblanchable erythema of intact skin. Discoloration of skin, warmth, edema (hardness, or pain pay be present).
Stage II ulcer
Partial thickness skin loss or blister. Loss of dermis presents a shallow open ulcer with red-pink wound bed without slough. May present as a intact or open/ruptured serum-filled or serosanguinous filled blister.
Stage III ulcer
Full-thickness Skin loss (fat visible). Down into the SubQ tissue. Can have slough, tunneling, eschar, undermining. Will need to be packed
Stave IV ulcer
Full Thickness Tissue Loss (Muscle/Bone Visible). May include slough and eschar. Often tunneling and undermining present.
Unstageable
Full thickness skin or tissue loss: depth unknown. Depth of the ulcer is obscured by slough (yellow, tan, gray, brown, green) and/or eschar (tan, brown or black) in the wound bed. It is either a stage III or IV. Stable (dry, adherent, intact without eryth
Suspected Deep Tissue Injury
Depth unknown. A purple or maroon localized area of discolored skin or blood filled blister caused by damage of underlying of soft tissue from pressure and/or shear. Most likely deep/full thickness damage underneath.
Granulation tissue
Red, moist tissue composed of new blood vessels, the presence of which indicates progression towards healing.
Slough
Soft yellow or white tissue (stringy substance attached to wound bed). Must be removed by clinician before wound is able to heal.
Eschar
Black or brown necrotic tissue which needs to be removed before healing can proceed.
Types of wound healing: Primary Intention
A surgical incision heals by primary intention. The skin edges are approximated (closed) and the risk of infection is low. Healing occurs quickly with minimal scar formation.
Types of wound healing: Secondary Intention
Wounds involving loss of tissue such as burn, pressure ulcer, severe laceration heals by secondary intention. Wound is left open until it becomes filled by scar tissue. Takes longer to heal so risk of infection is greater. If scaring is severe, loss of ti
Wound repair: Partial-Thickness
1. Inflammatory response-first 24 hrs after injury. Redness, swelling, serous exudiate.
2. Epithelial formation and migration- New cells form and cover wound bed. Approx 4-7 days.
Wound repair: Full-Thickness
1. Hemostasis- injured blood vessels constrict and platelets gather to stop bleeding. Clots form.
2. Inflammatory phase- Histamine release resulting in serum exudiate and white blood cell release into damaged tissues. Localized redness, edema, warmth, thr
Complications of Wound Healing
1. Hemorrhage: Externally or internally. Hemoglobin decrease, increased HR, decreased B/P
2. Hematoma: Localized collection of blood underneath tissues.
3. Infection: fever/hypothermic; inflammation/edema; thick purulent drainage (yellow/brown/green color
Risk factors for dehiscence/eviseration
1. Abdominal surgery
2. Obesity
3. Poor wound healing
4. Steroid use
5. Sudden strain (cough, vomit, sitting up)
Treatment for dehiscence
Pack wound
Treatment for eviseration
Medical emergency requiring surgical repair. Place sterile towel soaked in sterile saline over extruding tissues to prevent bacterial infection and drying of tissues.
Prevention of dehiscence/eviseration
Splinting with pillow.
Supportive devices: ab binders
Wound Assessment in emergency settings
1. Inspect: foreign bodies-glass, dirt, gravel. Irrigate (use goggles)
2. Size: width, depth, length
3. Tetanus toxoid injection: good for 10 years. Needs one if not within 5 years of shot.
Assessment of Skin: objective
Color, temperature, moisture, turgor, texture
Is the mouth pink/moist (hydrated) or dry/sticky?
Braden Scale.
What to inspect for in a wound
Clean, dry wound.
Edges approximated
Measurements
Wound bed and surrounding tissue.
Pressure Ulcer influencing factors
1. Nutrition: Calories, protein, vitamins (A&C), Zinc, hydration.
2. Tissue perfusion: Circulation, oxygenation, immune function. Some diseases threaten tissue perfusion i.e. PVD, DM, Anemia (hgb), smoking (vasoconstriction, cancer, immunosuppressant meds
Sanguineous
Bloody, indicates active bleeding.
Serosanguineous
Pale, pink, thinner, contains plasma and RBCs
Serous
Pale, yellow, watery
Purulent
Contains microorganisms: thick, pale yellow/tan/green, odor.
Braden Scale Categories
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
Skin Care Interventions
Hygiene: tepid bath, lotion, non-drying soaps, avoid puritis
Protect from sun, extreme heat/cold
Splinting, ab binders, wound supoort
Review sterile dressing change
Debridement
Dressings
Pressure Ulcer prevention
Braden scale interventions
Increase mobility
Turning schedules
30 degree lateral position recommended
Specialty beds/mattresses
Never massage reddened areas
Keep skin dry/clean
Apply moisture barrier ointment
Adequate nutrition and hydration: labs (total
Drain types
Penrose drain: sutured in place undre a dressing. A pin or clip prevents the drain from slipping further into wound.
Self-Suction: exert a constant low-pressure when bladder/container is fully compressed.
Wound Support
Montgomery straps
Ab binders
Elastic bandage
RICE
What do we assess after applying a bandage?
Skin distal to bandage for signs of circulatory impairment (coolness, pallor/cyanosis, diminished/absent pulses, swelling, numbness, tingling). Change dressings if soiled.
Cold Therapy
Vasoconstrictors: control bleeding
Decreases edema from acute injury.
Relieves pain
Contraindications for cold therapy
Neuropathy present
Edema from disease process
Shivering
Heat Therapy
Vasodilators: increases blood flow
Resolves inflammation
Relieves muscle stiffness, tension, spasms
Contraindications for heat therapy
Bleeding
Acute localized inflammation
Monitor pt with cardiovascular disease (dilation)