skin integrity and wound care

Skin Integrity and Wound Care103A

Pressure UlcersLocalized injury to skin and underlying tissue,

usually over a bony prominence.

Often results from pressure in combination with shear and/or friction.

May be caused by devices such as oxygen equipment, orthopedic devices, straps or tubing, as well as pressure from beds or chairs.

Risk Factors for Pressure Ulcer Development

Impaired sensory Impaired sensory perception/perception/

Alterations in LOCAlterations in LOC

ShearShear

Impaired mobilityImpaired mobility Nutrition and HydrationNutrition and Hydration

FrictionFriction MoistureMoisture

Stage I

Intact Skin with

Nonblanchable Redness

Stage IIPartial-thickness Skin Loss or Blister

Stage III

Full-thickness Skin Loss (Fat Visible)

Stage IVFull-Thickness Tissue Loss (Muscle/Bone Visible)

Suspected Deep-Tissue InjuryDepth unknown.

UnstageableFull-thickness Skin or Tissue Loss-Depth Unknown

PAIN The assessment of pain and

management of pain must be included in plan of care

Provide analgesic 30 minutes prior to wound care

Consider nonpharmacological interventions

Nursing Knowledge Base Prediction and prevention of pressure ulcers

Norton Scale Physical and mental condition, activity, mobility, and

continence

Braden Scale Sensory perception, moisture, activity, mobility,

nutrition, and friction and shear

Assessment Skin Presence of ulcers Mobility Nutrition and fluid status Pain Existing wounds, appearance, character Wound culture

Nursing Diagnosis and Planning Impaired Skin Integrity Risk for Infection Impaired Nutrition: less than body

requirements Acute or Chronic Pain Impaired Physical Mobility Ineffective Tissue Perfusion Impaired Tissue Integrity Disturbed Body Image

Implementation Health promotion

Topical skin care Protect bony prominences, skin barriers for

incontinence.

Positioning Turn every 1 to 2 hours as indicated.

Support surfaces Decrease the amount of pressure exerted over bony

prominences.

Implementation Nutrition and Hydration Appropriate Wound Treatments Pain Management Education of Patient and Caregivers Psychosocial Aspects

Summary Nursing interventions for reducing and

treating pressure ulcers need to be evaluated to determine if the client has met the identified outcomes or goals.

Take a Holistic, Multidisciplinary Approach. Do a Thorough Assessment…more than

once. Develop an Individualized Care Plan. Put Interventions into Place Without Delay. Commit to Care.

Thank You! Questions/comments?