Nursing A ConceptBased Approach to Learning VOLUME ONE
Nursing: A Concept-Based Approach to Learning VOLUME ONE | SECOND EDITION MODULE 21 Tissue Integrity Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Exemplar 21. 3 Pressure Ulcers Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Exemplar Learning Outcomes After reading about this exemplar, you will be able to: 1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of pressure ulcers. 2. Identify risk factors and prevention measures associated with pressure ulcers. Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Exemplar Learning Outcomes, continued After reading about this exemplar, you will be able to: 3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with pressure ulcers. 4. Formulate priority nursing diagnoses appropriate for an individual with pressure ulcers. Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Exemplar Learning Outcomes, continued After reading about this exemplar, you will be able to: 5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with pressure ulcers. 6. Plan evidence-based care for an individual with pressure ulcers and his or her family in collaboration with other members of the healthcare team. Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Exemplar Learning Outcomes, continued After reading about this exemplar, you will be able to: 7. Evaluate expected outcomes for an individual with pressure ulcers. Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Overview • Ischemic lesions of skin, underlying tissue § Causes necrosis and ulceration • High incidence in hospitals, long-term care facilities, home settings Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Etiology • Caused by external pressure that impairs blood flow • Caused by forces that tear and injure vessels § Shearing forces § Pressure Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Risk Factors • Immobility • Inadequate nutrition § Hypoproteinemia • Fecal and urinary incontinence § Skin maceration, excoriation • Decreased mental status • Diminished sensation • Excessive body heat Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Risk Factors, continued • Advanced age § § § Loss of lean body mass Generalized thinning of epidermis Decreased strength, elasticity of skin Increased dryness Diminished pain perception Diminished venous, arterial flow • Chronic medical conditions • Other factors Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Prevention • Providing nutrition • Maintaining skin hygiene • Avoiding skin trauma § Smooth, firm, wrinkle-free foundation § Frequent shifts in position • Correct positioning, transfer, turning • At least every 2 hours when client confined to bed § Proper lifting Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Prevention, continued • Providing supportive devices § Overlay mattress on top of standard bed mattress § Specialty beds replacing hospital beds § Kinetic beds • Continuous passive motion, oscillation Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Clinical Manifestations • Stage I § Nonblanchable erythema of intact skin • Stage II § Partial-thickness skin loss • Stage III § Full-thickness skin loss • Stage IV § Full-thickness skin loss with extensive destruction Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Clinical Manifestations, continued • Unstageable § Eschar present § Unable to assess depth, undermining Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Collaboration • Diagnostic tests § Determine presence of a secondary infection § Differentiate cause of ulcer • Surgery § Debridement • If eschar has formed § Autolytic debridement § Larval therapy Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Collaboration, continued • Pharmacologic therapy § Topical, systemic antibiotics § Dressings that maintain moisture • Iodine, silver sulfadiazine, medical-grade honey • Nonpharmacologic therapy § Patient education • Prevent ulcers • Care for present ulcers Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Products Used to Treat Pressure Ulcers • Stage I § Skin prep, granules § Hydrocolloid dressing § Transparent dressing • Stage II § Transparent dressing § Hydrocolloid dressing Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Products Used to Treat Pressure Ulcers, continued • Stage III § Wet-to dry gauze dressing with sterile NS § Hydrocolloid dressing § Proteolytic enzymes • Stage IV § Wet-to dry gauze dressing with sterile NS § Vacuum-assisted closure (VAC) Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Nursing Process • Prevention • Existing pressure ulcer(s) § Prolong treatment for other problems § Increase healthcare costs § Diminish client's quality of life Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Assessment • Inspect • Palpate • Document Location Size, presence of undermining Stage Color of wound bed, location of necrosis or eschar § Condition of wound margins § § Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Assessment, continued • Document, continued § § Integrity of surrounding skin Clinical signs of infection Client complaints of pain, discomfort Signs of infection Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Assessment, continued • Risk assessment tools § Braden Scale for Predicting Pressure Sore Risk § Norton Scale § Waterlow Scale § Should be used: • When client first enters healthcare agency • Whenever client's condition changes Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Diagnosis Risk for Impaired Skin Integrity Risk for Infection Imbalanced Nutrition: Less Than Body Requirements • Risk for Compromised Human Dignity • Situational Low Self-Esteem • • Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Planning • Immobile client reposition every 2 hours • Mobile client maintain, improve activity levels • Client will report any alterations • Client will articulate importance of maintaining adequate nutrition, hydration • Client will describe measures to protect, heal tissue Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Implementation: Maintain Skin Integrity • • • Conduct systematic skin inspection daily Clean skin when soiled, routine intervals Minimize environmental factors Avoid massage over bony prominences Minimize skin exposure to moisture Minimize skin injury due to friction, shearing Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Implementation: Maintain Skin Integrity, continued • Position client according to health status • Maintain head of bed at lowest elevation § Consistent with condition • Use assistive devices • Place client on pressure-reducing device • Chair-bound client § Use pressure-reducing devices Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Implementation: Prevent Infection of Pressure Ulcers • • • Maintain skin hygiene Maintain appropriate nutrition, hydration Recognize early stages Contact healthcare provider as necessary Maintain, improve current activity levels Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Implementation: Prevent Nutritional Imbalance • Process factors involved • Offer nutritional supplements • Consult with dietitian Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Implementation: Prevent Compromised Human Dignity and Situational Low Self-Esteem • Conduct physical exam for indicators § Abuse, neglect • Develop caring, trusting relationship • Teach, assist family members, caregivers § Importance of repositioning § Skin hygiene § Obtaining supportive devices Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
Evaluation • Treatment plan may need to be evaluated and modified as often as daily, depending on the assessment of client's skin integrity, client comfort and pain level • Diminished appetite • May need to consult with a nutritionist of dietician • Clients who are mobile should call if they discover another pressure ulcer or change in skin integrity Nursing: A Concept-Based Approach to Learning Volume One, Second Edition Copyright © 2015, 2011 by Pearson Education, Inc. All Rights Reserved
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