ressure ulcer

unrelleved pressure on a bony promlnenL frlcLlon sheer

MosL common slLes
Sacrum heels
CLher slLes back lllac cresL ears

lnfluenclng facLors
besL way Lo prevenL pressure ulcer ls Lo roLaLe every 2 hrs
Lakes abouL 30 mlnuLes Lo form a pressure ulcer
poor nuLrlLlon

ConLrlbuLlng facLors
Lxcesslve molsLure can break skln down and conLrlbuLe Lo pressure ulcer

8lsk lacLors
Advanced age
Anemla
ConLracLures
ulabeLes melllLus ( poor clrculaLlon unconLrolled blood glucose desLroy blood vessels
LlevaLed body LemperaLure

8lsk lacLors
lmmoblllLy
lmpalred clrculaLlon
lnconLlnence
Low dlasLollc blood pressure ( 60 mm PC)
MenLal deLerloraLlon
neurologlc dlsorders
CbeslLy clrculaLlon due Lo adlpose Llssue ls poor
aln need Lo be under conLrolled so LhaL paLlenL can sLarL movlng
rolonged surgeryneed Lo geL Lhe paLlenL movlng afLer surgery
vascular dlsease

Cllnlcal ManlfesLaLlons
Craded one Lo four
SLage 1 (mlnor) Lo sLage lv (severe)
Craded accordlng Lo deepesL level of Llssue damage
SLage l [usL Lhe epldermls and dermls uescrlbe as unblanchable eryLhema ( always
redpressure or noL)

ueep Llssue ln[ury from bone up

SLage Lwo
arLlal Lhlckness loss of dermls

SLage Lhree
lull Lhlckness skln
1o Lhe subcuLaneous may affecL Lhe muscle buL noL bone

SLage 4
lull Lhlckness loss can exLend Lo muscle bone
Cdor

Cllnlcal manlfesLaLlons lnfecLlon
slgns L leukocyLosls fever ( greaLer Lhan 101) odor dralnage necroLlc Llssue paln

CompllcaLlons
MosL common recuurence
CellullLls
Chronlc lnfecLlon
CsLeomyellLls as Lhe lnfecLlon grows ln Lhe bone lL creaLes dead bone so no blood can flow
Lhrough may need Lo remove Lhe bone
lL heals from Lhe boLLom up


AssessmenLL
Assess pressure ulcer rlsk on admlsslon and aL perlodlc lnLervals based on care seLLlng and
paLlenL's condlLlon

AssessmenL of paLlenL wlLh dark skln

lannlng
Cverall goals
no deLerloraLlon
8educe conLrlbulLlng facLors
noL develop an lnfecLlon
Pave heallng
Pave no recurrence

revenLlon
moblllze
remove excesslve molsLure