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Pressure Ulcers


Pressure Ulcers NU111

Marketplace > Kaplan University > NURSING > NU111 > Pressure Ulcers
Kaplan University
GPA 3.75

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Pressure ulcers and staging
Medical-Surgical I
Class Notes
pressure, sores, ulcers, Staging
25 ?




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This 6 page Class Notes was uploaded by BALNL on Thursday October 13, 2016. The Class Notes belongs to NU111 at Kaplan University taught by in Spring 2015. Since its upload, it has received 5 views. For similar materials see Medical-Surgical I in NURSING at Kaplan University.

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Date Created: 10/13/16
Unit 3 Assignment Notes – {Pressure Ulcers} Pressure ulcers = localized injury to skin and/or underlying tissue  usually over bony prominence  result of pressure, shear, or both Category/Stage I Ulcer  intact skin with non-blanchable skin  may be painful, firm, soft, warm/cool compared to adjacent tissue  non blanchable erythema (redness) ↳ defined area of redness that persists after pressure is applied Category/Stage II Ulcer  partial thickness loss of dermis ⟶shallow, open ⟶red, pink wound bed ⟶no slough  can be: ⟶intact ⟶open/ruptured serum filled ⟶serosanguinous-filled blister ⟶shiny, dry, without slough/bruising Category/Stage III Ulcer  full thickness tissue loss o subq fat may be visible  bone, tendon, muscle is not  some slough may be present  may include undermining/tunneling Category/Stage IV Ulcer  full thickness loss with exposed bone, tendon, and muscle o slough, eschar may be present o often include undermining/tunneling  extends into muscles and/or supporting structures Unstaged/unclassified  full thickness loss with base completely covered by slough in wound bed o either stage III or stage IV o mark as unstaged/unclassified if wound bed is no visible due to slough Suspected Deep Tissue Injury (sDTI)  purple/maroon, localized area of intact skin  blood-filled blister  area may be: o painful, firm, mushy, boggy, warmer/cooler than adjacent skin  may include thin blister over wound bed o further evolution includes thin eschar  may evolve to ulcerations  Staging: o Stage I  pink/red – unblanchable o Stage II  skin intactness with or without blisters  partial tissue loss  serum-filled blister healing ulcers do not digress = stage III is healing stage III not stage II  Inflammatory Phase o neutrophils and macrophages migrate to wound  removed bacteria, dead tissue, and debris o cytokines released  Proliferation Phase o angiogenesis  new capillaries form o granulation  fibroblasts create new collagen and extra cellular substances  appears beefy-red o epithelization  epithelial cells migrate to wound edges  migrate from remaining hair follicles  wound edges appear thin, pearly, silvery, and/or shiny  Maturation/Remodeling Phase o scar tissue mask  shrinking/thinning of scar  scar turns from red/pink to skin color  can last 1+ years Skin Tears ⟶wound caused by shear, friction and/or blunt force o results in skin separation ⟶can be partial thickness o separation of epidermis from dermis ⟶can be full thickness o both epidermis and dermis from underlying structures Extrinsic Risk Factors 1. corticosteroid and anti-inflammatory use 2. chronic disease polypharmacy 3. dry skin from frequent bathing/skin cleansers Most common on upper and lower extremities ISTAP Skin Tear Grading o Type I – no skin loss; linear tear/flap that can cover wound o Type II – partial flap loss; cannot reposition o Type III – total flap loss; exposing entire wound bed Payne-Martin grading o Category I – skin tear; no loss o Category II – skin tear; partial loss o Category III – skin tear; complete loss Skin Stripping  commonly found in neonates o result of removal of adhesives  characteristics: o partial thickness loss o may result in full loss if no subq tissue is present Arterial Ulcers  caused by impaired blood flow o lower legs/feet  results in ischemia, necrosis, and loss  causes – atherosclerosis  location – toes, dorsum of foot, lateral malleolus, distal lower leg  characteristics – round/regular shape | smooth edges | severe pain | minimal drainage Venous Ulcers  caused by venous system dysfunction o poor blood outflow from lower extremities o venous hypertension  prolonged venous hypertension results in vessel injury/damage o increased capillary permeability  partial to full thickness loss  location – between knees and ankles o often between lower calf and ankle | medial lower leg  characteristics – shallow, irregular shape | defined wound edge | moderate to large drainage present | mild to severe pain Diabetic Foot Ulcers  foot wounds  peripheral neuropathy o loss of sensation (Sensory) o causes imbalance between flexor and extensor muscles (Motor)  alters blood flow; dry skin (autonomic)  peripheral vascular disease  repetitive mechanical stress/excessive pressure  poorly controlled glucose levels o accelerates development  location – toe – interphalangeal joint, metatarsal head, plantar surface of foot, under heel  characteristics – partial to full with bone involvement | regular wound margins often surrounded by callous rim | low to moderate drainage Moisture-Associated Skin Damage  result of moisture exposure  inflammation and erosion  common causes of moisture o urine, stool o perspiration o wound exudate o effluent from estomy Incontinence-Associated Dermatitis (IAD)  prolonged exposure to urine, stool o urine overhydrates  ammonia in urine increases pH; impairs barrier o fecal enzymes weaken skin integrity  liquid stool = worst o location = buttocks, perineum, perianal area, possibly inner things o characteristics = usually partial thickness skin loss | irregular and indistinct borders | no exudate | no slough/eschar | burning pain Data Collection Step 1 – determine total number of pressure ulcers found during survey ⟶ if 0 enter 0; if 1+ or more move to Step 2 Step 2 = community acquired? hospital acquired? Step 3 = was hospital acquired acquired on survey unit? Community acquired ⟶presence upon admission ⟶survey was conducted on day 1 and pressure ulcer was present ⟶ulcers that worsen are still community acquired Hospital acquired ⟶developed after admin Unit Acquired ⟶new ulcer that formed after unit admin ⟶if ulcer was present at time of unit admin it is hospital acquired only!


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