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Pressure Ulcer Prevention

Nursing Technology Course
by

on 10 August 2013

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Transcript of Pressure Ulcer Prevention

Tip of the Iceberg
Unstageable
Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.
Stage 3
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
Stage 4
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable
Stage 1
Deep tissue injury
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.
pressure redistribution
Identify
co-morbidities

don' let your patients
skin get hit by this!
Braden subscales: moisture, sensory, activity, mobility, nutrition, friction and shear
Age (young or elderly)
Bed or Chairbound
Under or Overweight
Dehydration
Multisystem trauma/spinal cord/orthopedics
Chronic and end stage disease states- cardiac, diabetes, pulmonary
Poor circulation, anemia
History of previous pressure ulcers-stage 3 or 4
Immunosuppression- chemotherapy, radiation, disease states
Specific medications- steroids, anticoagulants, immunosuppressants,vasopressors
Behavioral and social factors- smoking
Medical devices


Comprehensive skin assessment
Pressure Ulcer Prevention
The evolution of pressure ulcers are often referred to as the tip of the iceberg as skin view presentations reflects a much deeper process as illustrated on the iceberg.
Use a validated pressure ulcer risk assessment tool
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons.
Stage 2
Partial thickness loss of dermis presenting as a shallow
open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister.Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation.

*Bruising indicates deep tissue injury.
80% pressure ulcers occur
-sacrum
-heels
-trochanters
-ischium
Check head to toe on admission and every shift/visit
Check under all devices!!!
Full transcript