Pressure ulcers

Nursing intervention (simplified)

-Use a written repositioning schedule -Reposition bed-bound person every two hour and chair-bound person every hour consistent with overall goals of care - teach chair-bound person shift weight every 15 minutes -Use lifting devices to move persons rather than drag them during transfers and position changes -Maintain head of the bed at the lowest degree of elevation consistent with patient's medical condition

risk factors categories

-immobility and inactivity -friction and shear -older age -moisture -nutrition -sensory perception -disease conditions -psychological factors and stress

Critical determinants of pressure ulcer

-intensity and duration of pressure -tolerance of the skin -supporting structures to pressure

List the six elements that Braden Scale includes.

-sensory perception -moisture -activity -mobility -nutrition -friction and shear

Aggressive prevention measures should be implemented for a patient in the general population with a pressure ulcer risk on the Braden Scale of less than or equal to

16 Individuals with a total score of 16 or less are considered at risk.

How many stages of pressure injuries?

4 stages

Risk assessment tools

Braden scale-total 23 points Individuals with total score of 16 or below are considered at risk

When to conduct assessment

Comprehensive skin assessment should be performed: -on admission to the unit, -daily -on transfer or discharge

A patient with anemia is at risk for developing pressure ulcers as a result of which of the following?

Diminished oxygen to the tissues. Anemia is an intrinsic risk factor for the development of pressure ulcers. This condition compromises oxygen delivery to the tissues by poor perfusion and thus cause poor or delayed healing and increased risk for pressure ulcers.

Nursing interventions to prevent pressure ulcer

Reposition bed-bound persons at least every two hours and chair-bound persons every hour consistent with overall goals of care. Consider postural alignment, distribution of weight, balance and stability, and pressure redistribution when positioning persons in chairs or wheelchairs. Teach chair-bound persons, who are able, to shift weight every 15 minutes. Use a written repositioning schedule. Place at-risk persons on pressure-redistributing mattress and chair cushion surfaces. Avoid using donut-type devices and sheepskin for pressure redistribution. Use pressure-redistributing devices in the operating room for individuals assessed to be at high risk for pressure ulcer development. Use lifting devices (e.g., trapeze or bed linen) to move persons rather than drag them during transfers and position changes. Use pillows or foam wedges to keep bony prominences, such as knees and ankles, from direct contact with each other. Pad skin subjected to device related pressure and inspect regularly. Use devices that eliminate pressure on the heels. For short-term use with cooperative patients, place pillows under the calf to raise the heels off the bed. Avoid positioning directly on the trochanter when using the side-lying position; use the 30° lateral inclined position. Maintain the head of the bed at or below 30° or at the lowest degree of elevation consistent with the patient's medical condition. Institute a rehabilitation program to maintain or improve mobility/activity status.

common areas for pressure ulcer development

occiput, shoulder, elbow, buttocks, heel, sacrum, ischial tuberosity,ear, hip, knee, ankle, rib cage, thigh, toes

5 common areas in supine position

occiput, shoulder, elbow, buttocks, heels

5 common areas in high-fowler position

occiput, shoulder, sacrum, ischial tuberosity, heels

shearing

the force exerted parallel to skin resulting from both gravity pushing down on the body and resistance between the patient and a surface// force created when the skin of a patient stays in one place as the deep fascia and skeletal muscle slide down with gravity, can also cause the pinching off of blood vessels which may lead to ischemia and tissue necrosis.

How often should a pressure ulcer risk assessment be performed for a patient who has recently undergone major abdominal procedures?

At least every day of their hospital stay. Comprehensive skin assessment shouldn't be a one-time event that's limited to admission. It needs to be repeated regularly to determine whether changes in skin condition have occurred. This provides an early baseline assessment and periodic reassessment throughout the confinement.

Complications

If left untreated, pressure injuries can produce ischemia and local infection. Advancing infection or cellulitis can lead to septicemia. Severe erythema may signal worsening cellulitis, which indicates that the offending organisms have invaded the tissue and are no longer localized.

An obese patient is at risk for skin breakdown and subsequent pressure ulcers. Which strategies should the nurse include in the patient care?

Maintaining the head of the bed no higher than 30 degrees and using a drawsheet when lifting the patient. Patient should be positioned not more than 30 degrees to reduce the amount of pressure on the sacral areas and decrease potential for patient to slide down foot of bed and incur a shear injury.

Give brief explanation on each of the element listed.

Sensory perception - altered level of consciousness is associated with increased risk. Moisture - Frequent or excessive contact with moisture can reduce the tensile strength of the skin, resulting in skin breakdown. Activity - Being bed or chair-bound is an important risk factor to pressure ulcer development. Mobility - requiring assistance of daily living and having limb contractures are important risk factors to pressure ulcer development. Nutrition - Essential nutrients are necessary for maximum tissue health, healing potential and immunity to infection. Friction & shear - Skin shear stretches and bends the vessels perfusing the overlying skin, leading to inhibited blood flow, skin ischemia and tissue damage.

An elderly patient who spends most of his waking hours in a chair is at risk for skin breakdown on his buttocks. What is the most appropriate action that the nurse should initiate with this patient?

Set a timer to ring at 15- to 20-minute intervals to remind the patient to change position. Using a timer to remind patient that positions changes need to occur while a patient is sitting in a chair every 15 minutes. Small shifts such as moving or repositioning the legs redistributes pressure over bony prominences. For a patient with a risk of sn breakdown, the nurse should assess and inspect skin at least daily. Sitting on a ring or donut-shaped devices not only cause direct force from the hard surface but also increase vascular congestion, which can lead to further tissue injury.

pressure ulcer

area of localised damage to the skin, muscle and underlying tissue caused by shear friction or unrelieved pressure, usually over bony prominence

7 common areas in side-lying position

ear, shoulder, elbow, hip, knee, ankle, heel

The patient with a nasogastric (NG) tube in place may experience skin breakdown

in the nose. Ulceration of the nares is associated with a nasogastric tube being present for a protracted period, specifically one that has been taped too firmly, failing to allow it to migrate with deglutition. This results in pressure necrosis of the edge of the nostril.

5 common areas in prone position

rib cage, elbow, thigh, knee, toes

When skin layers adhere to the linens and deeper tissue layer move downward, ________ damage occurs.

shear