Venous and pressure ulcers

1. Venous and pressure ulcers Integumentary System, PN 124

2. Stasis Ulcers • Causes • - chronic deep vein insufficiency • - delay of venous blood returning to the • central circulation • -severe varicose veins, burns, trauma, • sickle cell anemia, diabetes, neurogenic • disorders and heredity

3. Appearance • -Dry/rough looking skin • -Hard to the touch • -Loss of body hair • -Ulcers begin as small, tender, inflamed • -Edema around the ulcer • -Occasional purulent drainage • -Slow to heal

5. Assessment • Subjective Data • -Severity of ulcer pain • -worse with the leg dependent • -itching • -duration • -measures to treat the ulcer

6. Objective Data- • -Size • -location • -appearance • -Color -both in a dependent and elevated position • -Wound drainage -color and consistency • -edema • -Surrounding skin appearance -erythema, induration

7. Nursing Management • Limb elevation -encourages return of venous blood to the general circulation -increases arterial blood flow -to general circulation and lower extremities -decreased edema. • Compression dressings -Unna Boot

8. Infection Control • -aseptic technique with dressing changes -monitor for signs of infection -cellulitis • Antibiotics- -topical (Silvadine cream) -oral or IV

9. Debridement • -Removal of necrotic tissue • - Mechanical • -wet to dry dressings • -Chemical • - Enzyme (Santyl, Elase) • -Surgical • -used only if mechanical and chemical • means were ineffective • -removal via scalpel of necrotic tissue

11. Dressings • -Compression • -Unna boot, Ace bandages, TED socks • Pain Management • -Elevate legs, analgesics, topical • anesthetics • Nutrition • -Protein, Vitamin A, Vitamin c, Zinc

12. Pressure ulcers (Bedsores/decubitus ulcers) Causes -Pressure on the skin -collapse of capillaries -ischemia/redness-1 hour -tissue necrosis-after 2 hours -boney prominences -

14. Shearing • -Force exerted against the skin • -movement or repositioning • -Stretches and tears the blood vessels, • -reducing blood flow • -necrosis develops

15. Friction • _the force of 2 surfaces moving across on another • _the rubbing of skin against the sheets • _removes superficial skin • _increases the risk of skin breakdown

16. Moisture • - incontinence urine and feces • -wound drainage • -perspiration

17. Staging of Pressure Ulcers • Stage I • - Non-blanchable erythema of intact skin

18. Stage II Pressure ulcer • -Partial thickness skin loss -epidermis, dermis or both. • -Ulcer is superficial -abrasion, blister or shallow crater

19. Stage III Ulcer • -Full thickness skin loss -damage or necrosis to the subcutaneous tissue. • -May extend down to, but not through the • underlying fascia. • -Deep crater with/without undermining of the adjacent tissue.

20. Stage IV Ulcer • -Full thickness skin loss -extensive bone destruction, tissue necrosis, or damage to muscle, bone, or supporting structures -Undermining and sinus tracts

21. Surrounding skin • -intact edges • -erosion • -maceration • -erythema • -edema

22. Tools for risk assessment • Braden Assessment Tool • Norton Pressure Ulcer Scale

24. Norton Assessment Tool

25. Risk factors for pressure ulcers • 1. Impaired mobility • -bedbound • -wheelchair bound • -dependent on positioning • 2. Moisture • -incontinent of urine and/or feces, • -perspiration • -wound drainage

26. 3. Nutritionally compromised -underweight -obese -poor nutritional status -poor food/fluid intake -secondary to poor appetite -dysphasia -limited ability to feed themselves. • 4. Disease Process -diabetes -anemia -atherosclerosis, -edema 5. Vitamin and Mineral Deficiencies -vitamin A, C, E, Zinc

27. Prevention of Pressure Ulcers • Identify the at-risk patient • -elderly • -impaired mobility • -poor nutritional status -altered level of consciousness

28. Prevention of Pressure Ulcers • Pressure relieve • -written repositioning/ turning schedule • -30 degree position when side lying • -pillows and foam wedges • -turn sheet to reposition or lift patient in the bed • -encourage patients in wheelchairs to shift their weight every 15 minutes

30. Cleansing of the skin • -inspect the skin daily • -mild cleanser for bathing • -avoid massaging skin over a boney • prominence • -moisturizer on the skin • -protective barrier ointment for incontinent • patients • -clean the skin at the time of incontinence.

31. Pressure relieving mattress and cushions • -Egg carton mattress • -Geomatt mattress • -foam overlay mattress -comparatively inexpensive • -Air overlay mattress -placed over the hospital bed mattress -weight redistribution • -Clinitron Bed -mattress filled with small glass sand particles, -moisture flows through the mattress

32. KCI/Kin Air Bed • -mattress of air-inflated pillows divided into • sections • -pressure can be adjusted in each of the • sections according to the client’s needs • -air flow form the mattress to eliminate • moisture.

33. Client education • PREVENTION!!! • -most important aspect to be taught to client’s and their caregivers!! • 1. Turning, positioning and shifting -every 2-3 hours- even during the night. • 2. Observe skin daily • 3. Diet adequate in protein, vitamins, calories and good fluid intake. • 4. Notify the health care provider for any changes in the skin.

34. -After a pressure ulcer has appeared • -Reinforce aggressive turning, positioning and pressure relief. • -Home Health RN • -assess the wound • -instruct the client and/or caregiver -wound care -signs of healing vs. deterioration -homebound clients