1 / 65

Developed by HELEN HOLDER RN, BSN Alverno College Milwaukee holderhc@alverno

PRESSURE ULCER PROGRAM. Developed by HELEN HOLDER RN, BSN Alverno College Milwaukee holderhc@alverno.edu. This site was designed with nursing assistants in mind! You’ll learn: What is a pressure ulcer? What is really going on under the skin? What part does nutrition play?

libitha
Download Presentation

Developed by HELEN HOLDER RN, BSN Alverno College Milwaukee holderhc@alverno

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. PRESSURE ULCER PROGRAM Developed by HELEN HOLDER RN, BSN Alverno College Milwaukee holderhc@alverno.edu

  2. This site was designed with nursing assistants in mind! You’ll learn: What is a pressure ulcer? What is really going on under the skin? What part does nutrition play? What part do you play to keep them away?

  3. What should I know after viewing this site? • Be able to name layers and functions of the skin. • Name those at risk. • Explain how pressure ulcers are formed. • Become aware of complications from pressure ulcers • Understand the importance of nutrition. • Identify the important prevention techniques used by CNA’s. Printshop2005

  4. Why Skin? • One of the largest organs in the body • Vital for homeostasis • Protection • Retards water loss • Regulates body temperature • House of sensory nerves • Contains immune system cells • Breaks down and uses various chemicals • Excretes waste Printshop2005

  5. Layer by Layer • Skin has three layers • Epidermis- Outer most layer- 5 distinct layers • Dermis- Middle layer • Hypodermis or Subcutaneous Layer

  6. EPIDERMIS • Lacks blood vessels • Cells reproduce & grow and shed as “dry skin” • Contains melanocytes for skin color • Thickest area of epidermis: palms & soles

  7. DERMIS • Contains blood vessels • Binds epidermis to underlying tissue • Contains muscle fibers-arrector pili • Nerves scattered through out • Contains hair follicles, sebaceous & sweat glands • Thickness: 0.5mm eyelids to 3.0mm soles

  8. HYPODERMIS • Subcutaneous • Loose connective tissue & adipose tissue • Thickness varies • Holds major vessels in place that supply blood to skin • Insulates body • No definition from dermal layer

  9. A function of the skin is? • Tan nicely • Excrete waste known as diarrhea • Regulate the temperature of the body

  10. Name that layer! • Name the layer that contains muscle fiber. • Dermis • Subcutaneous • Epidermis

  11. Genetic Connection • NONE Those at risk: people with Peripheral vascular disease Diabetes Paralysis of limbs Casts Obese/Thin Printshop2005

  12. Picture This • Crowded church, packed pews, no cushions, sermon that goes on forever and no one can move. Once you have positioned yourself you are stuck for the duration. How does it feel on your hips and tailbone? We’re talking real pressure! Now think about how someone with no control over their movements feels. Perfect set up for pressure ulcers! Printshop2005

  13. How does that ulcer form? • Resident lying in bed on their back. • Buttocks, by force of gravity sink into mattress. • Soft tissue presses against the bones that don’t go anywhere. • Blood vessels are pinched between bone and weight of gravity. • Blood flow to soft tissue is cut off. • Cell starvation and death occur • Pressure ulcer is born.

  14. FIRST SIGN ISINFLAMMATION • Redness/non-blanching • Warmth • Swelling • Pain • Loss of function • FOR MORE INFORMATION ON INFLAMMATION: http://www.siumed.edu/~dking2/intro/inflam.htm Printshop2005 http://faculty.alverno.edu/bowneps/inflammation/inflammindex.htm Bowne,3/22/2006

  15. Staging • 4 levels progression • No open area Deep wound Printshop2005

  16. Stage I • Non-blanching redness • Intact skin • Precursor to pressure ulcer • Sorrentino, S.A., Mosby’s Textbook for Nursing Assistants, 6th Ed., St. Louis: Elsevier; 2004: pg. 587.

  17. Partial thickness skinloss Abrasion Blister Shallow Crater Stage II • Sorrentino, S.A., Mosby’s Textbook for Nursing Assistants, 6th Ed., St. Louis: Elsevier; 2004: pg. 587.

  18. Full thickness skinloss Not through fat layer Deep crater Damage or Necrosis Stage III • Sorrentino, S.A., Mosby’s Textbook for Nursing Assistants, 6th Ed., St. Louis: Elsevier; 2004: pg. 587.

  19. Extensive destruction Necrosis Muscle/Bone damage Tunneling Stage IV • Sorrentino, S.A., Mosby’s Textbook for Nursing Assistants, 6th Ed., St. Louis: Elsevier; 2004: pg. 587.

  20. Necrosis(cell death)

  21. What is one of the First Signs of Inflammation ? • Blanching • Warmth • Stress

  22. Blanching • Inflammation is characterized by redness at the site of tissue injury. If you lightly put your finger on the reddened area and exert slight pressure the area will not “whiten” or blanch. Printshop2005

  23. Warmth • Correct. Warmth is an indicator of inflammation due to the increased blood flow to the area. Printshop2005

  24. Stress • Try again. Stress may lead to a different type of ulcer but doesn’t usually lead to a “pressure” ulcer. Printshop2005

  25. A characteristic of Stage II is ? • Blister • Full thickness skin loss • Tunneling

  26. Yahoo! • Blistering is one of the early characteristics of the Stage II pressure ulcer. Printshop2005

  27. No • Full thickness skin loss happens in the Stage III pressure ulcer. The wound will appear as an open area and necrosis may be visible.

  28. Try again • Tunneling happens during Stage VI. Wounds will begin to produce deeper pockets as the tissue is eroded away. The pocket may be narrow and proceed to another area of tissue, hence the term “tunnel”. Printshop2005

  29. Factors that lead to Pressure Ulcers • Malnutrition Low protein intake Inability to feed self • Immobility • Incontinence urine/feces on skin Printshop2005

  30. Warning Signs of Malnutrition • Sudden/Recent weight loss • Dehydration • Decrease appetite Printshop2005

  31. What is Needed? • Elderly need at least 1200 calories/day • Protein- for repair & regrowth • Carbohydrates & Fats-Tissue maintenance & energy source • Vitamins- promote wound healing Printshop2005

  32. Protein • Best Sources: eggs milk cheese yogurt Printshop2005

  33. Carbohydrates & Fats • Carb sources Whole grains Cereal Rice • Unsaturated fats Olive oil Canola oil Safflower oil Printshop2005

  34. Vitamins • Vitamin C- for collagen formation Good Sources: Citrus fruit strawberries • Vitamins A & E- for tissue repair Good Sources: orange & green vegetables • Vitamin K- for normal blood clotting Good Sources: Green leafy vegetables Printshop2005

  35. Name a Symptom of Malnutrition • Sudden weight gain • Consistently decreased appetite • Excessive thirst

  36. NO • Sudden or recent weight loss is a symptom of malnutrition Printshop2005

  37. You’re Right • An elderly person that is not consistently eating at least 1200 calories per day, may be headed for the state of malnutrition Printshop2005

  38. Check again! • Dehydration is a sign of malnutrition. Excessive thirst is a symptom of Diabetes. Printshop2005

  39. Good Source of Vitamin C? • Green leafy vegetables • Liver • Strawberries

  40. Not this time • Vitamin K is found in green leafy vegetables Printshop2005

  41. Not Liver • Liver is high in iron and cholesterol but not Vitamin C Printshop2005

  42. Right you are! • Strawberries are a good source of Vitamin C and taste good too! Printshop2005

  43. PREVENTION • Best protections against pressure ulcers is observation, good skin care,mobility, and goodnutrition. • CNA’s importance----most direct contact with residents Microsoft Office XP2002

  44. CNA Role in Nutrition • Assist at Mealtime make it social and take your time feeding the resident. • Give supplements as required. Ensure or 2Cal or whatever other supplement is ordered. • Substitute food dislikes for preference. • Report & Record appropriately. Microsoft OfficeXP2002

  45. CNA Role in Immobility • Reduce pressure: Turn bed residents every 2 hours. Even a 15 degree turn helps to relieve pressure on skin surface. Use a written turning schedule so that others know in which direction the resident is to go. Microsoft OfficeXP2002

  46. Positioning • Position correctly! Use pillows to support joints Avoid skin touching skin Check to make sure no body part is hitting a wall or railing Remember! Check positioning in the chairs. Chairs too small or residents that lean to one side may have pressure. Microsoft OfficeXP2002

  47. Keep Resident Moving!! Printshop2005

  48. Shearing & Friction • Shearing- Skin layers slide in different directions • Friction- causes a rug burn on skin Microsoft OfficeXP2002

  49. Avoid Shearing & Friction • Use lifter sheet to move resident up in bed • Use assistance of over bed trapeze • Keep HOB 30 degreesor lower to avoid slipping down in bed • Cup heels & elbows during ROM exercises • Don’t drag heels over sheets when using lifts. PrintShop2005

  50. Importance of Skin Care • Check every 2 hours for incontinence. Feces, urine and even soap are abrasive to the skin due to a ph imbalance. PrintShop 2005

More Related