skin, wounds and nutrition part 2. pressure ulcers pressure ulcer definition (npuap) a pressure...
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Skin, Wounds and Nutrition Part 2
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Pressure UlcersPressure Ulcer Definition (NPUAP)
A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.
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Pressure Ulcer
A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is
yet to be elucidated.
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Who Gets Pressure Ulcers?
People who are immobile for extended periods Older adults Paralyzed Comatose
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Pressure UlcersPathophysiology
Neuropathic: interruption of autonomic reflex and circulatory reflex
Shear: mechanical force on epidermis Direct pressure: capillary closing pressure
32 mmHg Maceration / contamination
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Pressure
Inflammation
Edema
Small Vessel Thrombosis
Cell Death
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Pressure Ulcers
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Stages of Severity
National Pressure Ulcer Advisory Panel
Revised Definitions
February 2007
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Pressure UlcerSuspected Deep Tissue Injury:
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
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Pressure UlcerStage I:
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
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Pressure UlcerStage II:
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
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Pressure Ulcer Stage III:
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling
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Pressure Ulcer Stage IV:
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
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Patient at Risk
Activity PhysicalCondition
Nutritional Status
Continence MentalStatus
Mobility
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Management - Prevention
Recognize at risk Mobility Activity Sensory perception External apparatus
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Prevention Strategy
Pressure relief Clean, intact skin Nutrition Movement Patient/family education
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Management - PreventionAvoidance Pressure Turning Mattress overlay Air/water bed Air fluidized
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The Enemies
Pressure Friction/shear Heat Moisture
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High Interface Pressure
Pinches off capillary blood vessels that transport oxygen and nutrients to tissue
Without blood flow, tissue quickly dies and decomposes, forming a pressure ulcer
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Patient On the Back
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Patient on the Side