Term
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Definition
| ANY LESION CAUSED BY UNRELIEVED PRESSURE RESULTING IN DAMAGE OF UNDERLYING TISSUE”. |
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Term
PRESSURE ULCERS APPEARANCE
RANGE FROM
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Definition
| RANGE FROM NONBLANCHABLE ERYTHEMA OF INTACT SKIN TO FULL THICKNESS SKIN LOSS WITH EXTENSIVE DESTRUCTION OF UNDERLYING MUSCLE & BONE. |
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Term
| THE INCIDENCE OF PRESSURE ULCERS |
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Definition
| 8% IN THE HOSPITAL AND 2.4-23% IN LONG TERM CARE FACILITIES. |
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Term
| THE MAJOR CAUSE OF PRESSURE ULCER IS |
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Definition
PRESSURE.
THE HIGHER THE PRESSURE & THE LONGER THE DURATION THE MORE LIKELY THE SKIN IS TO BREAKDOWN. |
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Term
| WHAT HAPPENS WHEN THE EXTERNAL PRESSURE COLLAPSES CAPILLARIES |
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Definition
BLOOD FLOW THROUGH THE CAPILLARIES IS STOPPED.
IF THE PRESSURE IS NOT RELIEVED PLATELETS AGGREGATE SO THE CAPILLARIES REMAIN OCCLUDED.
NO OXYGEN & NUTRIENTS GET TO THE TISSUES & NO WASTES ARE REMOVED FROM THE AREA RESULTING IN ISCHEMIA AND TISSUE NECROSIS.
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Term
| THE AREAS MOST PRONE TO PRESSURE ULCERS ARE |
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Definition
| OVER BONY PROMINENCES BECAUSE THE TISSUES ARE COMPRESSED BETWEEN THE BONE & THE EXTERNAL PRESSURE SOURCE |
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Term
_______________IS AN EXTERNAL CONTRIBUTING FACTOR IN THE DEVELOPMENT OF PRESSURE ULCERS AND OCCURS WHEN THE HOB IS ELEVATED CAUSING GRAVITY TO PULL THE BODY DOWN WHILE THE RESISTANCE OF THE BED PULLS THE BODY UP.
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Definition
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Term
| WHEN SHEARING OCCURES THE SKIN...... |
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Definition
| REMAINS STATIONARY WHILE THE UNDERLYING TISSUE SHIFTS RESULTING IN KINKING, TEARING & THROMBOSIS OF THE BLOOD VESSELS RESULTING IN TISSUE ANOXIA, WHICH LEADS TO TISSUE NECROSIS. |
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Term
| External Contributing Factors |
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Definition
| FRICTION/MOISTURE, SHEARING |
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Term
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Definition
THE OUTER LAYER OF THE SKIN TO BE REMOVED.
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Term
| THE NURSE CAN DECREASE FRICTION BY |
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Definition
| USING A TURN SHEET TO PULL THE client UP IN BED RATHER THAN DRAGGING THE CLIENT SO THE SKIN DOESN’T SLIDE ON SHEET. |
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Term
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Definition
INCREASED EFFECTS OF SHEAR & PRESSURE,
MAKES THE SKIN HAVE INCREASED PERMEABILITY TO IRRITATING SUBSTANCES AND INCREASES THE LIKELIHOOD THAT THE SKIN WILL BE COLONIZED BY BACTERIA.
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Term
INTERNAL CONTRIBUTING FACTORS include:
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Definition
IMMOBILITY. IMPAIRED SENSORY PERCEPTION, THE ELDERLY, IMMUNOCOMPROMISED
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Term
| Clinical Manifestations IN A STAGE I PRESSURE ULCER |
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Definition
THE SKIN IS BRIGHT RED TO PINK BECAUSE OF EXCESSIVE VASODILITATION.
THE AREA DOES NOT BLANCH, THIS CONDITION PERSISTS FOR MORE THAN 1 HR. AFTER THE PRESSURE IS RELIEVED AND INDICATES TISSUE DAMAGE.
CAUSES DISCOMFORT SUCH AS TINGLING OR BURNING.
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Term
Clinical Manifestations
IN A STAGE II PRESSURE ULCER
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Definition
| PARTIAL THICKNESS SKIN LOSS INVOLVING THE EPIDERMIS &/OR THE DERMIS THAT APPEARS AS AN ABRASION, BLISTER, OR A SHALLOW CRATER. |
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Term
Clinical Manifestations
IN A STAGE III PRESSURE ULCER
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Definition
FULL THICKNESS SKIN LOSS WITH DAMAGE OR NECROSIS OF THE SUBCUTANEOUS TISSUE THAT MAY EXTEND DOWN TO THE FASCIA AND APPEARS AS A DEEP CRATER WITH OR WITHOUT UNDERMINING OF ADJACENT TISSUE.
IS USU. PAINLESS BECAUSE THE NERVES ARE DESTROYED.
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Term
Clinical Manifestations
IN A STAGE IV PRESSURE ULCER
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Definition
THERE IS FULL THICKNESS SKIN LOSS WITH EXTENSIVE DESTRUCTION, NECROSIS, OR DAMAGE TO MUSCLE, BONE, OR SUPPORTING STRUCTURE.
THERE IS UNDERMINING OF ADJACENT TISSUES & SINUS TRACTS MAY OCCUR
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Term
| STAGE II,III, AND IV PRESSURE ULCERS ALWAYS CONTAIN........ |
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Definition
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Term
STAGE II,III, AND IV PRESSURE ULCERS
OFTEN HAVE |
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Definition
| FOUL SMELLING DRAINAGE THAT RESULTS WHEN BACTERIA INCREASE IN NUMBER ENOUGH TO CAUSE INFECTION. |
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Term
Pressure Ulcers
DIAGNOSIS IS MADE BY
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Definition
| THE CLIENT’S HISTORY & THE PHYSICAL EXAM AND BY PROPER STAGING. |
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Term
| IN ORDER TO DO PROPER STAGING... |
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Definition
THE ESCHAR NEEDES TO BE REMOVED.
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Term
THE NURSE SHOULD NEVER REVERSE STAGE.
THIS MEANS........ |
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Definition
A STAGE IV PRESSURE ULCER IS ALWAYS A STAGE IV.
IT NEVER BECOMES STAGE III,II,I AS IT HEALS.
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Term
| INFECTION OF A PRESSURE ULCER IS DIAGNOSED BY |
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Definition
NEEDLE ASPIRATION OF FLUID FROM AN ULCER BIOPSY
NEVER BY SWABBING THE SURFACE OF THE WOUND BECAUSE THESE BACTERIA MAY BE DIFFERENT THAN WHAT’S REALLY CAUSING THE INFECTION DEEP INSIDE THE TISSUES.
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Term
MANAGING PRESSURE: NUTRITION
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Definition
INCREASED PROTEIN FOR HEALING AND WILL NEED INCREASED CALORIES TO SPARE THE PROTEIN FOR HEALING.
CLIENTS WHO ARE NOT ABLE TO EAT AN ADEQUATE MEALS WILL NEED TUBE FEEDINGS & NUTRITIONAL SUPPLEMENTS, INCLUDING VITAMINS A, C & ZINC, WHICH PROMOTE HEALING.
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Term
PRESSURE ULCERS Management:
SURGICAL |
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Definition
DIBRIDEMENT IS NEEDED IF AN ESCHAR OR NECROTIC TISSUE IS PRESENT
SKIN GRAFTS AND SURGICAL RECONSTRUCTION MAY BE NEEDED |
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Term
| THE NURSE SHOULD USE ALL MEANS TO PROVIDE PRESSURE RELIEF TO THE TISSUES: |
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Definition
CLIENTS SHOULD NEVER LAY ON A PRESSURE ULCER.
MAY NEED SPECIAL MATTRESSES
A REGULAR TURNING SCHEDULE.
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Term
| PREVENT PRESSURE ON BONEY PROMINENCES BY: |
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Definition
TURNING ALL CLIENTS AT LEAST Q2H.
PILLOW IS PLACED LENGTH-WISE AND THE HEEL SHOULD BE ALLOWED HANG OVER SO THERE IS NO PRESSURE ON IT.
SPECIAL EQUIPMENT SUCH AS EGGCRATE MATTRESSES, GEO-MATS, KCI BEDS OR OVERLAY MATTRESSES, SUCH AS THE 1ST STEP, PLACING A GEL PAD IN W/C’S, ANDTEACHING SCI CLIENTS TO PERFORM PRESSURE LIFTING Q15 MIN.
NO DONUTS OR RINGS
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Term
PRESSURE ULCERS
AND
ALCOHOL SKIN PRODUCTS |
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Definition
NO ALCOHOL SKIN PRODUCTS SHOULD BE USED BECAUSE ALCOHOL DRIES THE SKIN AND CAUSES CRACKING OF THE SKIN.
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Term
_____________ CAN BE USED IN SKIN FOLDS AND
HEEL & ELBOW PROTECTORS CAN BE USED TO PREVENT FRICTION.
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Definition
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