Pressure Ulcers

A patient with a pressure ulcer asks the nurse, "How could this have happened?" Which response from the nurse is appropriate?

"Compression of your skin led to a lack of blood flow." Compression of the skin impairs blood flow and can cause a pressure ulcer to form.

The charge nurse is leading a unit discussion on pressure ulcers. Which statements should the nurse include?

-"The risk is influenced by nutrition and activity." -"People with an inability to communicate are at high risk." -"They can be prevented by relieving pressure on the affected areas."

Negative Pressure Wound

-A suction tube and a guaze applied to a wound and connected to low-level negative pressure -used to remove fluid and infections material to promote granulation tissue * Never use on patient with anticoagulant exposed blood vessels, nerve or organs*

The nurse is evaluating a patient's risk for developing a pressure ulcer. Which patient characteristics does the nurse consider?

-Age -Activity -General health

Which information about pressure ulcer formation should be provided by the nurse to a patient with decreased mobility?

-Ambulate to the restroom frequently." -"Place pillows between your legs when sleeping." -"Shift your weight every 60 minutes while sitting down."

Pressure ulcer reducing prevention

-Devices are available that relieve (dynamic) or reduce (static) pressure, including specialty beds, mattresses, overlays, assistive devices -repositioning of immobile patients -pillows/padding to reduce pressure on bony prominence - occupational therapy and/or physical therapy implements specialty equipment and devices

Electrical Stimulation

-Low-Voltage pulse used to promote blood vessel growth and granulation of tissue -preformed by PT

Other Risk Factors for Pressure Ulcers

Anemia Contractures Diabetes mellitus Elevated body temperature Friction (rubbing of surfaces together) Impaired circulation Low diastolic blood pressure (<60 mm Hg) Mental deterioration Neurologic disorders Obesity Prolonged surgery Vascular disease Protein malnutrition

The nurse assesses a patient with diabetes mellitus who has a pressure ulcer on the heel. Which intervention should the nurse question while the patient is on bedrest?

Application of bilateral knee-high compression socks

The nurse is caring for patient with paraplegia. Which nursing action is important for preventing pressure ulcer formation in this patient?

Ask patient to participate in repositioning whenever possible

The nurse is caring for a patient with a pressure ulcer determined to be unstageable. What characteristics would the nurse expect?

Eschar is covering wound bed

decubitus ulcer

pressure ulcer

The patient on anticoagulant therapy has a pressure ulcer on the right foot that has a foul odor to the drainage. The patient has good peripheral pulses. The nurse anticipates the health care provider will prescribe which interventions?

-Obtain a wound drainage specimen for culture and sensitivity -Cushion foot to prevent contact between the ulcer and the bed -Have a dietitian evaluate nutrition needs and create a new diet plan

Primary risk factors of pressure ulcers

-Older Adults -Cognitive impairment -inability to mover or reposition

Hyperbaric Oxygen Therapy

-Oxygen is applied to the wound in a special chamber at 100% oxygen level and at higher than normal pressure to enhance the tissue oxygen concentration -this treatment is usually reserved for life- or limb-threatening wounds

Treatments/Therapies for wounds

-PT -Topical Therapy -Nutritional Therapy -Electrical Stimulation -Negative Pressure Wound therapy -Hyperbacaric Oxygen Therapy

Upon the initial home visit, the home health nurse notes the patient has a pressure ulcer that is red with a purulent discharge. Which patient information is vital for the home health nurse to obtain from the discharging hospital nurse to properly perform an initial assessment of the patient's pressure ulcer?

-Skin condition at discharge -Successful pressure-relief measures used -The measurements of the wound prior to discharge

What are some Lab/diagnostic used for pressure ulcers?

-Swab Cultures -Wound biopsies -check arterial blood flow -lab test to evaluate nutritional status

Prevention for Pressure Ulcers

-Use of The Braden Scale can assess a patient's risk -diabetes mellitus and peripheral arterial disease should be monitored for impaired circulation that would place them at risk for skin breakdown -importance of frequent repositioning and skin inspection

PT

-debride wounds by using whirlpool treatments

A medical-surgical nurse is caring for several patients. Which patient would the nurse expect to be at the highest risk for skin breakdown?

A 65-year-old patient who has bowel and bladder incontinence

The wound care nurse assesses a group of patients on the unit. Which patient is at risk of developing a pressure ulcer?

A patient with a spinal cord injury.

The nurse is caring for a patient with a stage 2 pressure ulcer. Which clinical manifestations does the nurse expect to observe?

Blistering Skin loss extending to dermis

Beige pus with a "fishy" odor

Colonization with Proteus

Greenish-blue pus causing staining of dressings and accompanied by a "fruity" odor

Colonization with Pseudomonas

Creamy yellow pus

Colonization with Staphylococcus

Brownish pus with a "fecal" odor

Colonization with aerobic coliform and Bacteroides (usually occurs after intestinal surgery)

The nurse is caring for a patient who has had a pressure ulcer for 3 days. When assessing the wound, which finding causes greatest concern for the nurse?

Creamy yellow exudate

What is a pressure ulcer?

Localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear

Blood-tinged amber fluid consisting of serum and red blood cells

Normal for first 48 hr after skin injury

Which conditions put a patient at risk for pressure ulcer development?

Poor nutrition Complete bed rest

The nurse is caring for an immobile older adult who is at high risk for pressure ulcer formation. Which measure is important to prevent pressure ulcer formation in this patient?

Provide foam material for the patient's heels

A patient is admitted with anemia, hypotension, malnutrition, and confusion. Which intervention should be used to prevent the patient from developing pressure ulcers?

Reposition the patient in the bed every 1 to 2 hours.

Intact skin Red color, may not blanch with pressure

Stage 1

Skin is broken Epidermal or dermal skin loss Superficial ulcer (abrasion, blister, shallow crater) Lack of bruising Wound bed red, pink, and moist Partial-thickness skin loss of the epidermis or dermis.

Stage 2

Full-thickness skin loss, including lower levels of dermis and subcutaneous tissue Adipose tissue visible Slough and/or eschar present Damage extends down to but not through the underlying fascia

Stage 3

Full-thickness skin loss Slough and eschar common Exposed or palpable fascia, muscle, tendon, or bone Epiboly (rolled edges) present

Stage 4

The nurse caring for a patient with a stage 2 pressure ulcer expects to prepare the patient for which diagnostic assessment?

Swab culture

A nurse is reviewing the electronic medical record of a patient with a stage 2 pressure ulcer to the iliac crest and notices the following entry: "Wound bed is pink with noticeable slough. It measures 2 cm * 2 cm. Packed with normal saline wet-to-damp dressing and covered with dry sterile dressing." Which data is missing from the documentation entry?

Type of drainage

Full-thickness skin loss Base completely covered with slough or eschar True depth of wound obscured

Unstageable

The nurse assesses the patient's Braden Scale score and finds the patient is at risk for skin breakdown. Which intervention should the nurse use while the patient is sitting in the chair?

Use a chair seat cushion

Patient reports pain prior to symptoms Inconsistency in temperature, texture or consistency between affected area and surrounding skin Skin discoloration Blood-filled blisters

suspected Deep tissue Injurt