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Project Pressure Learning

This document discusses pressure ulcers, including their definition, contributing factors, prevention strategies, and wound assessment components. A pressure ulcer is localized tissue damage caused by pressure, often found over bony prominences. Contributing factors include both intrinsic patient factors like malnutrition and extrinsic factors like pressure and moisture. Prevention strategies focus on managing pressure, reducing friction and shear, and maintaining cleanliness and moisture balance. A full wound assessment includes documenting location, stage, size, base tissues, exudate amount and type, odor, perimeter, pain, and signs of infection.

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59 views15 pages

Project Pressure Learning

This document discusses pressure ulcers, including their definition, contributing factors, prevention strategies, and wound assessment components. A pressure ulcer is localized tissue damage caused by pressure, often found over bony prominences. Contributing factors include both intrinsic patient factors like malnutrition and extrinsic factors like pressure and moisture. Prevention strategies focus on managing pressure, reducing friction and shear, and maintaining cleanliness and moisture balance. A full wound assessment includes documenting location, stage, size, base tissues, exudate amount and type, odor, perimeter, pain, and signs of infection.

Uploaded by

api-302329271
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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Pressure Ulcers

Ryan Shigley
Nurs 400
BYU - Idaho

What is a pressure ulcer?


Localized tissue damage or necrosis caused

by pressure
Often found over bony prominences

Contributing Factors
Intrinsic

Malnutrition

Dehydration

Impaired Mobility

Impaired Sensation

Decreased Level of Consciousness

Advanced Age

Infection

Chronic Conditions

Extrinsic

Pressure
Friction
Moisture
Incontinence
Shear

Prevention
Manage pressure, particularly over bony

prominences
Off-load pressure sites (ex. heels)
Reposition (Q hour/ chair, Q 2 hours/ bed)
Utilize pillows/ wedges for repositioning

Reduce friction and shear


Utilize draw sheets for repositioning
Utilize lifts or transfer devices

Mange Incontinence
Timely cleansing
Barrier creams and ointments

Wound Assessments
Location
Stage
Size
Base tissues
Exudates
Odor
Perimeter
Pain
Presence of Infection

Location
Location documentation includes which

extremity, nearest bony prominence or


anatomical landmark

Stage
Stage I- Intact skin with non-blanchable localized redness
Stage II- Partial thickness loss of dermis
May also present as intact or open serum filled blister

Stage III- Full thickness skin loss with visible subcutaneous

fat.
May include undermining or tunneling

Stage IV- Full thickness skin loss with exposed bone, tendon,

or muscle
Often includes undermining and tunneling

Unstageable- Full thickness skin loss with wound base covered

in slough or eschar
Suspected Deep Tissue Injury- Localized discoloration of intact
skin or blood-filled blister due to damaged underlying skin.

Stage

https://cias.rit.edu/faculty-staff/97/faculty/501

Size
Length- head-to-toe orientation at the longest

point
Width- perpendicular to length at widest point
Depth- perpendicular to wound base at
deepest point
Tunneling
Point of origin and direction of tunneling
Utilize the clock concept (12 oclock = pt. head)
Tunnel depth
Location of deepest point

Base Tissue
Eschar- Brown, black, or tan devitalized tissue

that adheres to wound edges


Slough- Soft, white, yellow, green, or tan
tissue that adheres to wound bed in strands or
clumps
Granulation- Pink, red moist tissue that is
shiny and granular in appearance
Epithelium- New pink tissue/ skin

Exudates
Amount
Slight- small amount to center of dressing
Moderate- contained within the dressing
Copious- extends beyond dressing

Type
Serous
Serosanguineous
Purulent

Odor
Most wounds have an odor
Assess after cleansing
Type of dressing, hygiene, and presence of

nonviable tissue will all affect odor

Perimeter
Wound edges (approximated, rolled,

calloused)
Periwound skin
Indurated- abnormal hardening related to

edema
Erythema- redness
Macerated- loss of pigmentation, soft, and
friable

Pain
Include location, type, patient rating, patient

description, and nonverbal indicators

Presence of Infection
Redness and warmth to surrounding tissues
Pain/ tenderness
Friable granulation
Unusual odor/ Malodorous
Purulent drainage
Systemic signs and symptoms

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