PRESSURE ULCER ASSESSMENT AND PREVENTION Ann Marie Lanza

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PRESSURE ULCER ASSESSMENT AND PREVENTION Ann Marie Lanza Bisciello

PRESSURE ULCER ASSESSMENT AND PREVENTION Ann Marie Lanza Bisciello

Pressure Ulcer Causes • Pressure compresses soft tissue over a bony prominence • Friction

Pressure Ulcer Causes • Pressure compresses soft tissue over a bony prominence • Friction • Shear

Risk Factors • • • Advanced age Immobility Incontinence Infection Low blood pressure Malnutrition

Risk Factors • • • Advanced age Immobility Incontinence Infection Low blood pressure Malnutrition

Assessment Goals and Etiologic Factors • • • Initial Assessment Determine etiologic factors Assess

Assessment Goals and Etiologic Factors • • • Initial Assessment Determine etiologic factors Assess ability to heal Assess wound status Assess impact on quality of life Serial Assessments Weekly Follow-up Assessment Changes in wound status to mandate change in therapy

Assessment • • • PUSH Tool-Pressure Ulcer Scale for Healing Measure Length and Width

Assessment • • • PUSH Tool-Pressure Ulcer Scale for Healing Measure Length and Width Exudate amount Tissue type present in the wound bed o o o 4 -Necrotic Tissue 3 -Slough 2 -Granulation Tissue 1 -Epithelial Tissue 0 -Closed

Staging Stage 1 Stage 3 Stage 2 Stage 4

Staging Stage 1 Stage 3 Stage 2 Stage 4

Staging DTI Unstageable

Staging DTI Unstageable

Video of Staging Pressure Ulcer Staging Educational and Clinical Resources How would you stage

Video of Staging Pressure Ulcer Staging Educational and Clinical Resources How would you stage this wound? Unstageable

Pressure Ulcer Treatment and Prevention 1. Pressure ulcer identification 2. Initial assessment 3. Education

Pressure Ulcer Treatment and Prevention 1. Pressure ulcer identification 2. Initial assessment 3. Education and development of treatment plan 5. Management of tissue loads 4. Nutritional assessment and support 6. Ulcer care; managing bacterial colonization and infection 7. Is ulcer healing? 8. Monitor 9. Reassessment of treatment plan and evaluation of adherence.

References • Bryant, R. A. , Nix, D. P. , (2007) Acute and chronic

References • Bryant, R. A. , Nix, D. P. , (2007) Acute and chronic wounds Current management concepts • www. WOCN. org • Educational and Clinical Resources

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