About
Superficial to deep tissue ischemia resulting from prolonged pressure on boney prominences and or skin surfaces. Staging can be from stage I ( superficial, non-blanchable erythema) to stage IV ( Deep tissue necrosis extending down to the muscle fascia and underlying bone.
Assess
Braden or Norton scale to determine risk; size ( length, width, depth); color ( red- well granulated; black- necrotic); drainage, sloughing, superficial or deep, blanching, redness, edema, tunneling, maceration, location, sensation
Complications
Infection; sepsis; tissue necrosis; gangrene
Diagnosis
- Acute pain related to tissue damage
- Impaired skin integrity related to physical immobility
- Risk for infection related to physical immobility
Goals
- The client will regain integrity of skin surface.
- The client will be free from infection.
- The client will identify strategies to decrease risks of pressure ulcer formation.
Interventions
- Identify clients at increased risks for pressure ulcers and initiate preventative measures immediately.
- Monitor pressure ulcer, documenting LxWxD, characteristics, color, odor, etc.
- Apply pressure reducing surfaces on mattress.
- Turn bed-bound client at least every two hours, maintaining a turning schedule.
- Maintain clean, dry skin.
- Avoid massaging bony prominences.
- Prevent friction and shear when lifting client in bed.
- Encourage high protein meals to aid in wound healing.
- Administer topical dressings as ordered.
- Teach client and family how to decrease risk of skin breakdown.
- Encourage active participation in ADL's as much as the client is able to tolerate.
- Consult with OT/ PT for strengthening exercises, ambulation techniques.
- Monitor for signs/ symptoms of complications.
ليست هناك تعليقات:
إرسال تعليق