Skin Integrity and Wound Care

Skin Integrity and - Skin Integrity and Wound Care Pressure Ulcers Localized area of tissue necrosis that develop when soft tissue is compressed

Info iconThis preview shows pages 1–3. Sign up to view the full content.

View Full Document Right Arrow Icon
Skin Integrity and Wound Care Pressure Ulcers k Localized area of tissue necrosis that develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time o Any client with decreased mobility, decreased sensory perception, fecal, or urinary incontinence, and/or poor nutrition are at risk for pressure ulcers o Pressure is the major cause o If pressure applied over a capillary exceeds the normal capillary pressure, the vessel is occluded, causing tissues ischemia o After tissue ischemia, if the pressure is relieved and the blood returns, the skin turns red (reactive hyperemia) o The area does not blanch, deep tissue damage is suspected o Blanching is seen when normal red tones of the light skinned client are absent. Blanching does not occur in clients with darkly pigmented skin o Characteristics of Dark Skin at risk for Breakdown: o Natural or halogen light is the best source for assessing skin. o Fluorsenct light source should be avoided (it casts a bluish hue, making accurate assessment difficult) o Color appear darker than surrounding skin, may have purplish/bluish hue o Initial warm when compared to surrounding skin, later coolness as tissue is devitalized o Indurated, edema, soft, boggy, taut, shiny and scaly Risks for Pressure Ulcers k Impaired sensory perception o Have clients that are away and oriented change positions or request assistance o Impaired mobility o Alteration in level of consciousness o Shear force parallel to skin resulting from gravity pushing down on the body and resistance between the client and a surface; affects deep tissue layers o Friction mechanical force exerted when skin is dragged across a coarse surface; affects epidermis o Moisture Classification of Pressure Ulcers k Stage 1 : changes in one or more of the following: skin temp, tissue consistency, and/or sensation, defined area of persistent redness in lightly pigmented skin, red, blue or purple in darker skin tones, no open skin areas o Stage 2 : partial-thickness skin loss involving epidermis and/or dermis; superficial, presents as an abrasion, blister or shallow crater o Stage 3 : full-thickness skin loss involving damage or necrosis of sub Q tissue that may extend down, not through underlying fascia; seen as a deep crater with our without undermining of adjacent tissue
Background image of page 1

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Stage 4 : full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures o Red, moist tissue indication granulation tissue, which means it is progressing towards healing o Yellow tissue is a characteristic of slough, which must be removed before the wound can heal o Black or brown tissue is generally eschar (necrotic), which must be removed before healing can proceed o Wound disruption of normal anatomical structure and function that results from pathological processes beginning internally or externally to the involved organs Wound classifications Description Causes Implications for healing
Background image of page 2
Image of page 3
This is the end of the preview. Sign up to access the rest of the document.

This note was uploaded on 05/04/2008 for the course NURS 120 taught by Professor Rominowski during the Spring '08 term at Lady of the Lake.

Page1 / 14

Skin Integrity and - Skin Integrity and Wound Care Pressure Ulcers Localized area of tissue necrosis that develop when soft tissue is compressed

This preview shows document pages 1 - 3. Sign up to view the full document.

View Full Document Right Arrow Icon
Ask a homework question - tutors are online