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Pressure Ulcer Prevention - Coggle Diagram
Pressure Ulcer Prevention
Pathophysiology
When prolonged pressure occurs on an area of the body, the vessels underneath occlude, leading to decreased circulation. This leads to tissue ischemia in the area and allows for tissue to breakdown.
Interventions
Perform thorough skin assessment every shift
Stage 1- Erythema or redness is present, but is non-blanchable, meaning when you press into it, there is no shift of color to white.. The area stays red when applying pressure
Staging
Stage 3- We see full thickness loss of skin. We may be able to see some fatty tissue. Now imagine the apple with a small bite taken out of it. The skin is gone, along with some of the underlying fruit of the apple.
Stage 2- If we see a break in the skin, the ulcer is automatically a stage 2. Typical policies may include putting in a Wound and Skin Consult for all ulcers stage 2 and above. Stage 2 could also present as a ruptured or fluid filled blister. Skin is unattached to wound bed. Imagine an apple with just the red skin peeled off.
Stage 4- there is full thickness loss of the skin and the tissue. We most likely can see tendon, muscle, and or bone. Often there is tunneling and undermining. Meaning the tissue under the skin is breaking down surrounding the open wound. Can be measured in depth by placing a long sterile q-tip into tunnel, and marking on the q-tip when it exits the body. Slough (yellow in appearance) and Eschar (black) are most likely present in the wound bed. To continue the apple analogy, the apple in this case would have several bites taken in one spot, all the way to the core.
Unstageable and Deep tissue injury- and unstable pressure ulcer means that the wound bed is not visible, most likely due to necrotic tissue on top of it. A deep tissue injury or DTI is when the area is purple or dark, we are unsure of the depth. The underlying tissue may feel mushy to the touch.
Document and Perform Braden Scale Assessment every shift
Mobility:
Completely Immobile (1)
Very Limited (2)
Slightly Limited (3)
No Limitations (4)
Activity:
Bedfast (1)
Chairfast (2)
Walks Occasionally (3)
Walks Frequently (4)
Moisture:
Constantly Moist (1)
Often Moist (2)
Occasionally Moist (3)
Rarely Moist (4)
Nutrition:
Very Poor (1)
includes NPO or clear liquid diet > 5 days
Probably Inadequate (2)
Adequate (3)
includes enteral feeds or TPN
Excellent (4)
Sensory Perception: Completely Limited (1)
Very Limited (2)
Slightly Limited (3)
No Impairment (4)
Friction and Shear:
Problem (1)
Potential Problem (2)
No apparent problem (3)
The Total is added together, a score 12 or less is high risk for pressure ulcer
Turn and Position Patient every 2 hours while in bed
Help patient shift weight every hour that they're up in the chair
Utilize foam wedges to position patient in bed
Utilize Prevalon Boots to minimize heel breakdown
Use Pressure relieving mattresses for bed bound patients
Patient Education: Sitting in one position for too long promotes skin breakdown, please shift your position for every 2 hours in bed, and every hour when sitting in the chair
Utilize Allevyn Dressings for prevention. Place on coccyx, heels, elbows, other bony prominences
Risk Factors
Loss of sensory perception: unable to percieve the associated pain
Immobility
Inability to follow directions ("shift your weight every two hours")
Poor Nutrition: inadequate protein and vitamin intake leads to tissues being more susceptible to damage, and delayed healing
Incontinence
Pronounced bony prominences
Altered Circulation
Friction (bed linens folded or bunched up underneath patient)