Case study pressure ulcers
. What intervention can you initiate to protect R.L.'s heels
Elevate R.L.'s heals with a pillow or apply heel-protector boots
Why are patients placed on specialty mattresses still at risk for skin breakdown
Even a specialty mattress can not eliminate areas of pressure on a patient's body. Also, other factors contribute to a higher risk of skin breakdown such as skin moisture, nutrition, and mobility.
What problems can be created by packing a wound too full?
If the wound is packed too full or if there is too much gauze, the wound healing environment may become too dry; a dry environment will delay healing and prompt the wound to remain concave and possible exacerbate. Also, too much packing may create more pressure in the wound, causing the edges of the wound to extend out.
Describe 6 interventions aimed at minimizing friction and shear.
Pad and protect vulnerable areas and prominences Utilize a draw sheet and positioning devices when moving or repositioning the patient Maintain a microclimate that minimizes perspiration Maintain a semi-fowlers position Turn and reposition the patient every 2 hours Elevate the patient's heels
How often should patients be reassessed for the risk of developing an injury
There is general consensus from most pressure ulcer clinical guidelines to do a risk assessment on admission, at discharge, and whenever the patient's clinical condition changes. The appropriate interval for routine reassessment remains unclear. Studies by Bergstrom and Braden, found that in a skilled nursing facility, 80 percent of pressure ulcers develop within 2 weeks of admission and 96 percent develop within 3 weeks of admission. The Institute for Healthcare Improvement has recently recommended that in hospitalized patients, pressure ulcer risk assessment be done every 24 hours rather than the previous suggestion of every 48 hours.
Elevated skin temperature and perspiration increase risk for pressure injury. Write 4 specific measures to manage the microclimate.
Use minimal bedding Place a fan in the room Set the thermostat to a cool temperature
What factors influence the choice of a wound dressing?
1. The characteristics of the wound could be analyzed, like the wound could be moist or dry, it could bleed very easily and could also be painful. 2. The type of the tissue where the wound was present could be analyzed properly, like the tissue could be epithelial, necrotic and granulated. 3. The fragility of the affected area of the skin
Describe the technique for packing a tunneled wound.
1. The materials that are necessary for healing of the wound should be assembled first. This includes the sterile solutions for wetting, packing and dressing the wounds effectively. Also, included is medical tape, swabs of cotton, clean towels, scissors and sterile water. 2. The affected area should be cleaned properly where the dressing has to be performed. Hands are washed properly. 3. The packing material should be prepared. The packing material should be cut according to the particular length that is needed. 4. Hands are washed again, and gloves are applied. 5. The packing material could be kept onto the wound. It should be winged out for release of excess solution from it. Gently, it is placed on top of the wound and is then wrapped by dressing it from the outer side. 6. It is made up of the gauze sponge squares, it is used to cover the wound tightly and to seal it comfortably.
What is a tunneling wound? What risk factors are associated with tunneling?
A tunneling wound is a wound that has reached the tissue beneath the skin and has begun to erode past the wound edge; a pocket or tunnel will result beneath the skin at the wound edge. Some risk factors associated with wound tunneling may include: Infection Pressure and Friction Improper Wound Dressing Comorbidities Medications
What major factors increase risk for developing a pressure injury
Advanced age Immobility friction, shear Poor nutrition Excessive moisture and incontinence Altered level of consciousness Poor perfusion Certain skin infections Comorbid conditions Vascular disease Hx of previous pressure damage
Compare friction and shear
Friction is the rubbing of two surfaces against one another. Shear is a combination of friction and gravity that can compress vessels and skin and cause breakdown.
What are the advantages of using a validated risk assessment tool to document her skin condition on admission
Objectivity Focus on prevention rather than treatment Identifying "at risk" population
Write an outcome related to R.L.'s skin integrity.
Patient reports any altered sensation or pain at site of tissue impairment Patient describes measures to protect and heal the tissue, including wound care.
Why is a specialty mattress used for immobile or compromised patients
Specialty mattresses distribute the patient's weight more evenly to avoid areas of pressure
staging of pressure ulcer
Stage 1 - no broken skin; the area is reddened and non-blanchable Stage 2 - the skin is broken forming an ulcer; it may appear as a blister filled with clear fluid; the skin may become necrotic Stage 3 - the skin is broken and the wound is extending into the tissue beneath the skin; fat may be present in the wound bed and tunneling may occur Stage 4 - the pressure injury is very deep, possibly exposing muscle, tendon, and bone; there is typically extensive damage such as necrotic tissue and tunneling
Each health care setting should have a policy that outlines how to assess patients' risk for developing a pressure injury. What should be included in that assessment?
The Braden Scale is composed of six subscales that reflect sensory perception, skin moisture, activity, mobility, friction and shear, and nutritional status. Five of the sub-scales are rated from one (1) (least favourable) to four (4) (most favourable); friction and shear sub-scale is rated from one (1) to three (3). A total of 23 points is possible. The lower the score, the higher the risk for pressure ulcer development Total score is only a number to guide interventions.
What risk factor does using a draw sheet prevent or minimize?
Using a draw sheet will minimize the amount of frictional force when moving the patient
What wound documentation is necessary
What type of wound it is & location 2. Whether it is a partial wound or full thickness 3. The stage of the wound 4. The size of the wound 5. If tunneling is present 6. Drainage of the wound should be analyzed 7. The features of the surrounding tissues are also analyzed 8. The pain, infections, or healing conditions are assessed for their proper analyzation 9. The various effects of the healing procedures could be carefully documented for its easy access and treatment 10. The treatment plans that are involved in relation to the ulcers and the patient's condition should be accessed.
Why do the heels have the greatest incidence of breakdown, even when the patient is on a specialty mattress?
When a patient lies supine, the weight of their lower legs and feet rests on their heels. Heels also have poor tissue perfusion and little muscle tissue to absorb the pressure.
Knowing that R.L. is frail, has right-sided weakness, and has a pressure injury, what consultations or referrals could you initiate?
Wound Care Specialist Physical Therapist Dietitian
Which instructions will you give to the UAP helping you care for R.L.? Select all that apply. a. Assess R.L.'s skin status every shift b. Develop an every-2-hour turn schedule c. Use the appropriate sheets on the airflow bed d. Keep R.L.'s head of bed below a 30-degree angle e. Assist with hygiene measures when R.L. is incontinent f. Empty and measure output in the urine collection device
b. Develop an every-2-hour turn schedule c. Use the appropriate sheets on the airflow bed d. Keep R.L.'s head of bed below a 30-degree angle e. Assist with hygiene measures when R.L. is incontinent f. Empty and measure output in the urine collection device
When collecting a wound culture with a swab, the nurse should culture the a. Wound drainage b. Healthy-appearing tissue c. Most necrotic-appearing tissue d. Very outer edges of the wound
b. Healthy-appearing tissue