Skin Integrity: Power Point: Ulcers Flashcards Preview

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Flashcards in Skin Integrity: Power Point: Ulcers Deck (19)
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1

Localized injury to the skin, usually over a bony prominence, as a result of pressure, or pressure in

pressure ulcer

2

any force that causes slippage between a pair of contiguous articulated parts in a direction that parallels the plane in which they contact

shear

3

The rubbing of one object or surface against another

friction

4

the scope of ulcer problems annually

1,000,000 new ulcers
$6 billion
2.2 million medicare days

5

extrinsic factors of pressure ulcers

excessive uniaxial pressure, friction or shear forces, impact injury, heat, moisture, posture, incontinence

6

intrinsic factors of pressure ulcers

immobility, sensory loss, age, disease, body type, poor nutrition, infection, incontinence

7

Incontinence is both

extrinsic and intrinsic factor

8

wound assessment checklist

Location
Stage
Drainage (amount, color, odor)
Size
Pressure redistribution
Viable tissue in wound
Dressing used
Nutritional assessment (albumin)
Undermining/Tunneling

9

Topical Treatment

Damp to dry (debridement)
Nutrient rich salves
Hyperoxygenation
Wound Vac

10

Surgical Treatment

Debriedment
Skin grafts

11

Prevention of Pressure Ulcers

Braden Scale Assessments

12

Braden Scale Assessment includes measuring of....

Sensory perception
Moisture contact
Activity
Nutrition
Friction & Shear

13

Do the Braden Scale Assessment....

Every patient, Every Shift

14

Scoring of the Braden Scale

rated 1-4 (shear 1-3)
19-23 – no risk
15-18 – low risk
13-14 – moderate risk
10-12 – high risk
<9 – very high risk

15

moderate risk (13-14)`

frequent turning
facilitating maximal remobilization
protecting the patient's heels
providing a pressure-reducing support surface
providing foam wedges for 30-degree lateral positioning
managing moisture, nutrition, and friction and shear.

16

high risk (10-12)

increases the frequency of turning
supplements turning with small shifts in position
facilitates maximal mobilization
protects the patient's heels
provides a pressure-reducing support surface;
provides foam wedges for 30-degree lateral positioning
manages moisture, nutrition, and friction and shear

17

very high risk (9 or below)

Add a pressure-relieving surface if the patient has intractable pain, severe pain exacerbated by turning, or additional risk factors such as immobility and malnutrition.
A lowair-loss bed is no substitute for a turning schedule.

18

High Risk Sites

Bony Prominence
Occiput
Ear~
Scapula
Elbow
spinous process
Sacrum
Heel
malleolus
pretibial crest
knee
trochanter
chin

19

Preventative Measures

Adequate hydration/nutrition
Pressure reducing devices
Client/family/staff support
Improve activity
Specialty mattresses
Keep skin dry and clean