Pressure Ulcer Presentation Brenda Holmes MSN, RN September 7, 2007
Pressure Ulcer Presentation <ul><li>Objectives </li></ul><ul><ul><li>Students will be able to: </li></ul></ul><ul><ul><ul>...
Pressure Ulcer Presentation <ul><li>What do you know about pressure ulcer? </li></ul>
Pressure Ulcer Presentation <ul><li>Epidermis </li></ul><ul><li>Dermis </li></ul><ul><li>Subcutaneous layer </li></ul>
Pressure Ulcer Presentation <ul><li>Bony prominence </li></ul><ul><ul><li>Head, Scapula, Vertebrae </li></ul></ul><ul><ul>...
Pressure Ulcer Presentation <ul><li>At risk for pressure ulcer </li></ul><ul><ul><li>A person that remains in one position...
Pressure Ulcer Presentation <ul><li>Types of pressure relieving devices </li></ul><ul><ul><li>Heel protectors </li></ul></...
Pressure Ulcer Presentation <ul><li>Braden Scale </li></ul><ul><li>New Stages of Pressure Ulcer </li></ul><ul><ul><li>New ...
Pressure Ulcer Presentation <ul><li>Suspected deep tissue injury </li></ul><ul><ul><li>Purple or maroon localized area of ...
Pressure Ulcer Presentation <ul><li>Stage I </li></ul><ul><ul><li>Nonblanchable erythematic </li></ul></ul><ul><li>Treatme...
Pressure Ulcer Presentation <ul><li>Stage 2 </li></ul><ul><ul><li>Partial thickness loss of dermis as a shallow crater </l...
Pressure Ulcer Presentation <ul><li>Stage III </li></ul><ul><ul><li>Full thickness tissue loss </li></ul></ul><ul><ul><li>...
Pressure Ulcer Presentation <ul><li>Stage IV </li></ul><ul><ul><li>Full thickness loss with exposed bone or tendon </li></...
Pressure Ulcer Presentation <ul><li>Unstageable </li></ul><ul><ul><li>Full thickness tissue loss with base covered by esch...
Pressure Ulcer Presentation <ul><li>Nurses’ responsibility </li></ul><ul><ul><li>Address issue immediately </li></ul></ul>...
Pressure Ulcer Presentation <ul><li>Nursing Assistant’s responsibility </li></ul><ul><ul><li>Turn resident/patient every 2...
Pressure Ulcer Presentation <ul><li>Treatments </li></ul><ul><ul><li>Heel protectors </li></ul></ul><ul><ul><li>Turn q 2 h...
Pressure Ulcer Presentation
Conclusion <ul><li>PREVENTION </li></ul>
Pressure Ulcer Presentation <ul><li>Reference </li></ul><ul><li>National Pressure Ulcer Advisory Panel (2007). http://www...
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Pressure ulcer presentation3

Published on: Mar 4, 2016
Published in: Health & Medicine      
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Transcripts - Pressure ulcer presentation3

  • 1. Pressure Ulcer Presentation Brenda Holmes MSN, RN September 7, 2007
  • 2. Pressure Ulcer Presentation <ul><li>Objectives </li></ul><ul><ul><li>Students will be able to: </li></ul></ul><ul><ul><ul><li>identify each stage of pressure ulcers. </li></ul></ul></ul><ul><ul><ul><li>know procedures in preventing pressure ulcers. </li></ul></ul></ul><ul><ul><ul><li>to follow through with the care. </li></ul></ul></ul>
  • 3. Pressure Ulcer Presentation <ul><li>What do you know about pressure ulcer? </li></ul>
  • 4. Pressure Ulcer Presentation <ul><li>Epidermis </li></ul><ul><li>Dermis </li></ul><ul><li>Subcutaneous layer </li></ul>
  • 5. Pressure Ulcer Presentation <ul><li>Bony prominence </li></ul><ul><ul><li>Head, Scapula, Vertebrae </li></ul></ul><ul><ul><li>Elbows, Between knees, Ankles, Heels </li></ul></ul><ul><ul><li>Hips, Sacral, Coccyx </li></ul></ul>
  • 6. Pressure Ulcer Presentation <ul><li>At risk for pressure ulcer </li></ul><ul><ul><li>A person that remains in one position due to inability to move self </li></ul></ul><ul><ul><li>Old age </li></ul></ul><ul><ul><li>Poor nutrition and lack of fluids </li></ul></ul><ul><ul><li>Moisture </li></ul></ul><ul><ul><li>Cardiovascular or respiratory problems </li></ul></ul><ul><ul><li>Friction and shearing injuries </li></ul></ul>
  • 7. Pressure Ulcer Presentation <ul><li>Types of pressure relieving devices </li></ul><ul><ul><li>Heel protectors </li></ul></ul><ul><ul><li>Elbow protectors </li></ul></ul><ul><ul><li>Bed cradle </li></ul></ul><ul><ul><li>Footboard </li></ul></ul><ul><ul><li>Air flow mattress </li></ul></ul><ul><ul><li>Alternating pressure bed </li></ul></ul>
  • 8. Pressure Ulcer Presentation <ul><li>Braden Scale </li></ul><ul><li>New Stages of Pressure Ulcer </li></ul><ul><ul><li>New as of February 2007 </li></ul></ul><ul><ul><ul><li>(Suspected) Deep Tissue Injury </li></ul></ul></ul><ul><ul><ul><li>Stage 1 </li></ul></ul></ul><ul><ul><ul><li>Stage II </li></ul></ul></ul><ul><ul><ul><li>Stage III </li></ul></ul></ul><ul><ul><ul><li>Stage IV </li></ul></ul></ul><ul><ul><ul><li>Unstageable </li></ul></ul></ul>
  • 9. Pressure Ulcer Presentation <ul><li>Suspected deep tissue injury </li></ul><ul><ul><li>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 </li></ul></ul>
  • 10. Pressure Ulcer Presentation <ul><li>Stage I </li></ul><ul><ul><li>Nonblanchable erythematic </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Repositioning </li></ul></ul><ul><ul><li>Relieving devices </li></ul></ul><ul><ul><li>Heel or elbow protectors </li></ul></ul><ul><ul><li>Skin barriers </li></ul></ul>
  • 11. Pressure Ulcer Presentation <ul><li>Stage 2 </li></ul><ul><ul><li>Partial thickness loss of dermis as a shallow crater </li></ul></ul><ul><ul><li>Pink wound bed </li></ul></ul><ul><ul><li>No slough (yellow) </li></ul></ul><ul><ul><li>May be intact or open blister </li></ul></ul>
  • 12. Pressure Ulcer Presentation <ul><li>Stage III </li></ul><ul><ul><li>Full thickness tissue loss </li></ul></ul><ul><ul><li>Subcutaneous fat may be visible but bone, tendon, or muscle not exposed </li></ul></ul><ul><ul><li>Slough may be present but not the depth of the tissue loss </li></ul></ul>
  • 13. Pressure Ulcer Presentation <ul><li>Stage IV </li></ul><ul><ul><li>Full thickness loss with exposed bone or tendon </li></ul></ul><ul><ul><li>Slough or eschar can be visible in some parts of the wound bed </li></ul></ul><ul><ul><li>Can include tunneling or undermining </li></ul></ul>
  • 14. Pressure Ulcer Presentation <ul><li>Unstageable </li></ul><ul><ul><li>Full thickness tissue loss with base covered by eschar (black, tan, brown, or slough (yellow, green, tan, gray, or brown) </li></ul></ul>
  • 15. Pressure Ulcer Presentation <ul><li>Nurses’ responsibility </li></ul><ul><ul><li>Address issue immediately </li></ul></ul><ul><ul><li>Start pressure ulcer preventative measures as soon as MD is notified </li></ul></ul><ul><ul><li>Turn patient q 2hours </li></ul></ul><ul><ul><li>Inform dietician if open wound is present </li></ul></ul><ul><ul><li>Measure/describe wound on admission </li></ul></ul><ul><ul><ul><li>and weekly </li></ul></ul></ul>
  • 16. Pressure Ulcer Presentation <ul><li>Nursing Assistant’s responsibility </li></ul><ul><ul><li>Turn resident/patient every 2 hours </li></ul></ul><ul><ul><li>Provide peri-rectal care after each incontinent episode </li></ul></ul><ul><ul><li>Apply lotion or cream after each incontinent episode (DO NOT MASSAGE) </li></ul></ul><ul><ul><li>Report any skin integrity issue to primary care nurse </li></ul></ul><ul><ul><li>Assist primary care nurse as needed with wound care (as set by each facility) </li></ul></ul>
  • 17. Pressure Ulcer Presentation <ul><li>Treatments </li></ul><ul><ul><li>Heel protectors </li></ul></ul><ul><ul><li>Turn q 2 hours </li></ul></ul><ul><ul><li>Specialty mattress </li></ul></ul><ul><ul><li>Creams, ointments, dressings, wound vac as ordered by MD </li></ul></ul><ul><ul><li>Nutritional support i.e. dietary consult, increase protein, vitamin support (Vitamin C and Zinc) </li></ul></ul>
  • 18. Pressure Ulcer Presentation
  • 19. Conclusion <ul><li>PREVENTION </li></ul>
  • 20. Pressure Ulcer Presentation <ul><li>Reference </li></ul><ul><li>National Pressure Ulcer Advisory Panel (2007). http://www.npuap.org </li></ul><ul><li>Black, J. M. & Black, S. B. (2004). Deep tissue injury, case study. Wounds from http://www.medscape.com/viewarticle/466563 </li></ul>

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