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Move it or Lose it! Prevention of Pressure Ulcers

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by

de dcourage

on 5 October 2013

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Transcript of Move it or Lose it! Prevention of Pressure Ulcers

Pressure Ulcer
Assessment.Prevention.Care
For early identification of patients risk of developing pressure ulcers and their effective management

To prevent the formation of pressure ulcers by identifying and assessing the severity of risk in all patients.

To initiate individual nursing care plans by preventative procedures based on the risk assessment performed.
Objectives
A
pressure ulcer
is an area of localized damage to the skin and underlying tissue that is caused by pressure, shear, friction and/or a combination of these.
Ischemic lesions
resulting from impaired circulation due to pressure on the skin and underlying structures, particularly over bony prominences.
Pressure Ulcer
Pressure ulcers
occur most commonly over a bony prominence like the sacrum, ischial tuberosity and the trochanter.

Pressure ulcers
may develop on any part of the body for example under a splint or cast. Medical devices and external fixations regularly the cause of pressure damage; tubes, oxymeter meters, oxygen masks, etc.
Stages of Pressure Ulcer
Pressure Points
Stage 1
Stage 2
Stage 3
1
2
3
Stage 4
Intact skin with non-blanchable redness/erythema of intact skin of a localized area usually over a bony prominence.
Further description-
Discoloration of the skin, warmth, oedema, hardness may also be used as indicators, particularly on individual with darker skin.
Partial thickness loss of epidermis and dermis. The ulcer is superficial and appears as an abrasion, blister, or a shallow crater.

Further description:
Presents as a shiny or dry shallow ulcer without slough or bruising
Full thickness tissue loss.
Subcutaneous fat may be visible
but bone, tendon or muscle
are not exposed.
Full thickness tissue loss with exposed bone, tendon or muscle, tissue necrosis, or damage to muscle, bone, or supporting structures( such as tendons and joint capsules)
Factors in the formation of pressure ulcer
Tissue tolerance
- The integrity of the skin
Shear
– occurs when the skeleton slides downwards with gravity while the skin remains in the original position stretching and tearing of blood vessels causing tissue ischemia
Friction
- occurs when two surfaces moves across each other removing superficial layers of the skin usually over a bony prominence.

Patient extremes of age,
Diabetes mellitus
Edema
Vasoconstrictive diseases
Immobility
Poor Nutrition/Hydration
Gel pad arm on arm boards to relieve pressure on elbows

Gel pad to heel areas through suspension

Sheets, patient gown and linen savers; no creases or folds beneath patient

Positioning straps; applied securely and not tightly so as 2 fingers can fit smoothly between patient skin and strap

Avoid high semi-fowlers position for extended periods as it increases the shear and pressure forces in the sacral area.
Avoid pooling of fluids and/or secretions under patients; keep skin dry at all times

Take special care of blood pressure cuff areas and rotate site if necessary

Skin antiseptic agents( povidine iodine) will cause irritation and tissue damage to neonates and infants and require complete removal after the procedure with sterile water or saline to prevent absorption.
PATIENT EDUCATION
Risk Factors
Documentation
Skin edema (skin is rigid, shiny )
Skin discomfort( pain, itching, loss of sensation)
Skin blanching, abscess or absence of skin layers
By Kerry, Carina, Liz (with a K), and de (with a b)
Treat with Tender Care
Remember:
FTZROX!
Pad, Position, Prevent
Skin hygiene
Skin color
Skin moisture
Skin temperature
Skin integrity
Skin scarring
Patient skin assessment and documentation
to be performed on all patients to include:
Eat healthy foods:
fruits and vegetables will do just fine.
(just the grapes, not the wine!)
Stay hydrated:

It will drink the water for the skin
or it gets the sores again...
Change position every 2 hours:

Roll 'em, Roll 'em, Roll 'em, keep your loved ones rollin
Keep the bed linens smooth:
bed linen wrinkles lead to bad skin crinkles
Keep a very close eye on the skin over high risk areas
a picture is worth a thousand words
Any Questions?
yo
Plan of care
Preventive measures performed
Specific treatment given and response
Pressure ulcer stage, location, size(length,width and depth) color and appearance of wound bed.
Changes since last assessment
Any other form for data collection
A Nursing Incident Report to be recorded for any newly discovered patient pressure ulcer.
References:
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick47.html

http://chamran.sums.ac.ir/amouzesh/Nanda/www.nandanursingdiagnosislist.org/nursing-
diagnosis-for-pressure-ulcers/default.htm

http://www.rehabnurse.org/pdf/GeriatricsPressureUlcer.pdf

http://www.aacn.org/wd/cetests/media/a1120013.pdf

http://www.ncbi.nlm.nih.gov/pubmed/16160463 (Risk factors)

http://www.npuap.org/wp-content/uploads/2012/01/A-UA-pr-ul1.pdf
NPSG.14.01.01
Assess and periodically reassess each
resident’s risk for developing a pressure ulcer and take action to address any identified risks.
JCAHO National Patient Goal
Pressure ulcers (PU) are one of the five most common problems experienced by patients in healthcare facilities.

Pressure ulcers increased by 80% between 1993 and 2006.

Pressure ulcers are both high cost and high volume adverse events, the majority of which can be prevented.

In 2006, the mean cost of treating a patient with the primary diagnosis of PU in a hospital was $1200/day.
Just the facts, ma'am
NANDA, NANDA
RHYMES WITH PANDA
Impaired skin Integrity
r/t physical immobility
aeb 5x2cm wound on sacrum
Goals:
To regain integrity of skin surface
To report any altered sensation or pain at site of skin impairment
Will demonstrate understanding of plan to heal skin and prevent reinjury
Describes measures to protect and heal the skin and to care for any skin lesion
Full transcript