PressureUlcer2.pdf - ACTIVE LEARNING TEMPLATE System Disorder STUDENT NAME Decubitus Ulcer(pressure ulcers Mod 3 DISORDER\/DISEASE PROCESS REVIEW MODULE

PressureUlcer2.pdf - ACTIVE LEARNING TEMPLATE System...

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Unformatted text preview: ACTIVE LEARNING TEMPLATE: System Disorder STUDENT NAME _____________________________________ Decubitus Ulcer (pressure ulcers) Mod 3 DISORDER/DISEASE PROCESS __________________________________________________________ REVIEW MODULE CHAPTER ___________ Alterations in Health (Diagnosis) A localized injury to the skin and other underlying tissues, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction. Pathophysiology Related to Client Problem Pressure is a major cause of decubitus ulcers - pressure intensity, pressure duration, and tissue tolerance. Obstructed blood flow. Capillary pressure exceeds normal pressure range. Health Promotion and Disease Prevention Turning every two hours, or encouraging patients who are independently mobile to move around regularly, or as much as they are able. ASSESSMENT SAFETY CONSIDERATIONS Risk Factors Expected Findings Prolonged sedentary positioning. Impaired sensory perception. Impaired mobility Alteration in level of consciousness Shear force Friction Moisture Stage 1 - non-blanchable redness (painful, warmer, may not have visible blanching) Stage 2 - Partial thickness (red-pink wound bed without slough) Stage 3 - Full thickness skin loss (bone, tendon, and muscle are not exposed; slough may be present but not obscure) Stage 4 - Full thickness tissue loss (bone, tendon and muscle are exposed - slough or eschar may be present) Unstageable - Full thickness skin of tissue loss, depth unknown (obscured by slough or eschar in wound bed) Suspected Deep tissue injury - depth unknown Laboratory Tests Diagnostic Procedures None? Visual assessment PATIENT-CENTERED CARE Nursing Care Complications Medications Client Education Topical skin care PREVENTION Turn patients every 2 hours. Regularly check skin integrity. Therapeutic Procedures CONTINUE Turn patients every 2 hours. Regularly check skin integrity. Support surfaces. Proper nutrition. ACTIVE LEARNING TEMPLATES Prevention of decubitus ulcers is optimal, and would help decrease healthcare costs. Move regularly, whenever able. If mobility restricted, have someone else help with positioning and movement. Interprofessional Care Correct documentation to ensure proper management of pressure ulcers. Left untreated, decubitus ulcers will progress into further skin breakdown causing further tissue damage, potentially leading to infections. ...
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