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Williams - Pressure Ulcers : - Coggle Diagram
Williams - Pressure Ulcers :
Risk Factors
Impaired activity / mobility
Impaired sensory perception
Inadequate hydration / nutrition
Incontinence / moisture
Diabetes mellitus
Peripheral vascular disease
Chronic illness
Prolonged bedrest
Age (Ex: old age, young age)
Nursing Interventions
Perform routine skin assessments
Risk assessment
Maintain skin integrity / skin care
Skin barrier cream / devices
Frequent turning & repositioning
Support surfaces (Ex: cushion / mattress)
Assess for signs & symptoms of infection
Wound care
Adequate hydration & nutrition ro prevent imbalances
Patient Education
Check skin daily
Encourage consumption of healthy diet and adequate hydration
Refrain from sitting / lying in same position for a long period of time
Signs / symptoms of a pressure ulcer
When to call doctor
Always keep skin clean & dry
Potenial Complications
Slow ulcer healing
Tissue necrosis
Infection of the ulcer
Sepsis
Death
Advancement of ulcer stage
Pathophysiology
Injuries to skin and underlying tissue that develop after prolonged pressure to a particular area
Common on the heels, sacrum, and over bony prominences (Ex: elbows, shoulder blades, and back of head)
Also called decubitus ulcers or bedsores
Develop and progress quickly but are preventable & treatable
Assessment
Subjective Data: Areas of skin tenderness, Pain burning of skin, Itchy skin, Mobility, Abnormal skin bruising
Objective Date: Changes in skin color texture, Blanching, Skin turgor, Swelling, Signs/Symptoms of infection, Drainage from wounds, Palpate for heat & Pain, Braden Scale, Temperature of skin, Moisture level
Pressure Ulcer Stages
Stage 2: open skin, pink / red, blister
Stage 3: Exposed subcutaneous tissue
Stage 1: non-blanch able erythema of intact skin
Stage 4: Exposed muscle / bone
Ethiology
Fracture
Shear
Pressure