Fundamentals of Nursing Chapter 48

Risk Factors for Pressure Ulcers

• Confusion or disorientation prevents patients from recognizing and relieving pressure, increasing ulcer risk.
• Key additional predisposing factors: impaired sensory perception, impaired mobility, shear, friction, and moisture.
• Diet low in calories and fat, muscular pain, and shortness of breath are not recognized risk factors.

Primary Causes of Decubitus Ulcers

• Pressure remains the primary cause, with intensity, duration, and tissue tolerance critical in ulcer development.
• Ischemic injury can occur when pressure exceeds 12 to 32 mm Hg on capillaries.
• Skin breakdown may arise from both high pressure over a short period and low pressure over longer durations.

Indicators of Pressure Ulcer Risk

• Fecal incontinence significantly heightens the risk due to prolonged moisture on the skin.
• Other observations, such as food intake or mild skin irritations, do not indicate imminent risk for pressure ulcers.

Staging of Pressure Ulcers

• A healing pressure ulcer retains its stage designation (e.g., a stage III ulcer that is healing is termed a "healing stage III pressure ulcer").
• Stage II ulcers exhibit partial-thickness skin loss without slough, presenting as abrasions or blisters.

Importance of Lighting in Skin Assessment

• Halogen or natural light is essential for accurate skin assessments, especially on patients with darkly pigmented skin.
• Incorrect lighting can distort assessment findings, preventing proper identification of skin issues.

Types of Wound Healing

• Pressure ulcers are examples of full-thickness wounds healing by scar formation.
• Wounds healing primarily through tissue regeneration involve minimal tissue loss and include procedures like laparoscopic surgeries.

Resurfacing of Wounds

• Wounds that are kept moist can resurface within 4 days, while those exposed to air may take up to 6-7 days.
• The timeframe for epithelial proliferation varies based on the type of wound care provided.

Healing Characteristics

• Granulation tissue indicates positive healing progression in full-thickness wounds.
• Presence of eschar, slough, or purulent drainage signifies complications such as infection or improper healing.

Complications in Wound Healing

• A hematoma, characterized by bluish discoloration and swelling, indicates possible complications and requires careful monitoring.
• Dehiscence is signaled by patient complaints of a sensation of something "giving way."

Nutritional Support for Wound Healing

• Protein is crucial for effective wound healing; it supports physiological processes involved in tissue repair.
• Vitamins A and C, along with zinc and copper, are also essential for optimal healing, while fats and carbohydrates do not require special increases.

Psychological Impact of Wounds

• Patients' concerns about appearance and odor from wounds can affect self-concept, indicating psychological distress.
• Responses to wound conditions can reveal underlying feelings about body image and healing progress.

Emergency Care for Lacerations

• Initial action should focus on inspecting the wound for bleeding.
• Subsequent assessments should include checking for foreign bodies and assessing the need for tetanus prophylaxis.

Priorities in Wound Care

• Before changing dressings or managing drainage, it’s vital to gather all necessary supplies to ensure an efficient and organized approach to wound care.### Wound Care and Pressure Ulcer Management
• Administer analgesics 30 minutes prior to dressing changes to minimize pain associated with removal.
• Sudden decrease in wound drainage requires assessment for blockage; notify the physician if suspected.
• Low-air-loss therapy units are effective for patients with stage IV pressure ulcers to prevent skin breakdown.
• Débridement is essential for necrotic tissue to promote healing and prevent infection in pressure ulcers.
• Use noncytotoxic cleansers like normal saline for clean granulating wounds to avoid harming healing tissue.

Skin Integrity Assessment

• Regularly assess skin for signs of ulcer development; monitor pressure points and bony prominences.
• Braden scale scores assist in assessing a patient's risk for skin breakdown based on sensory perception and mobility.
• Nursing diagnoses related to skin include "Impaired skin integrity" for patients with stage IV pressure ulcers and "Ineffective tissue perfusion" for areas with redness that does not blanch.

Infection Risk and Prevention

• Hand hygiene is the primary intervention to prevent infection in patients with pressure ulcers.
• Consult a registered dietitian to optimize the diet for wound healing.
• Educate families about infection signs and wound care, particularly for unconscious or bedridden patients.

Patient Mobility and Repositioning

• Encourage adequate pain control to increase patient comfort and mobility, thus reducing pressure ulcer risk.
• Limit chair sitting time to 2 hours, using cushions to alleviate pressure.
• When repositioning, utilize safe methods like a transfer sliding board to avoid shearing forces.

Dressing Changes and Patient Comfort

• Explain dressing change procedures to alleviate patient anxiety and involve them in their care.
• Clean wounds in a direction from least to most contaminated to minimize infection risk.
• Abdominal binders support large incisions post-surgery, particularly during movement and coughing.

General Care Strategies

• Employ clean techniques for dressing changes in home care to manage costs and reduce infection risk.
• Position patients appropriately to reduce pressure and improve comfort, adjusting care based on individual capabilities and needs.### Postoperative Care for Medial Meniscus Repair
• Pain management post-surgery includes elevating the knee and applying ice to minimize edema and control bleeding.
• Brace application is supportive but does not directly manage pain.
• Vital signs monitoring is routine but not a direct pain intervention.
• Pulses should be checked to ensure circulation, not specifically for pain management.

Braden Scale Assessment

• Braden scale scores range from 6 (high risk) to 23 (low risk); a score of 18 indicates pressure ulcer risk.
• A score of 23 signifies optimal skin integrity and a decreasing risk for skin breakdown after interventions.

Multi-disciplinary Approach for Pressure Ulcers

• Consults for patients with stage II pressure ulcers should include:
  • Registered dietitian for nutritional support.
  • Wound care nurse specializing in wound management.
  • Physical therapist to enhance mobility and minimize risk.
  • Case management for arranging outside care.
• Spiritual or medication needs are generally secondary and not core consults unless necessary.

Factors Influencing Wound Healing

• Key influencing factors include:
  • Nutrition: Essential for repair.
  • Tissue perfusion: Adequate oxygen significantly aids healing.
  • Infection: Delays healing and increases tissue damage.
  • Age: Older patients experience delayed healing.
• Evisceration and hemorrhage are complications but not direct influences on the healing process.

Skin Integrity Assessment Questions

• Important questions during skin integrity assessment include:
  • Ability to change positions to reduce pressure.
  • Sensitivity to temperature for self-protection.
  • Frequency of toileting to assess incontinence risk.
  • Pain during movement indicating mobility issues.

Components of Skin Assessment

• Skin assessment involves evaluating:
  • Hyperemia: Observing abnormal reactions post blood flow obstruction.
  • Induration: Detecting hard areas on the skin.
  • Blanching: Testing reddened areas for circulation recovery.
  • Skin temperature: Monitoring for blood flow changes.
• Mobility and nutritional status are crucial but are overall assessment aspects rather than direct skin assessment components.

Responsibilities Before Applying Bandages

• Inspect for abrasions, edema, and skin integrity.
• Cover exposed wounds with sterile dressings.
• Assess current dressing conditions for needed changes.
• Evaluate the skin beneath the bandage for circulatory integrity.

Outcomes Indicating Progress in Pressure Ulcer Care

• Positive outcomes toward improving skin integrity include:
  • Preventing injury to skin and tissues.
  • Reducing various levels of skin and tissue injury.
  • Restoring skin integrity.
• Patient expectations and perceptions provide useful feedback but are not direct measurable outcomes.

Test your knowledge on skin integrity and wound care with these practice questions. This quiz focuses on key concepts and risk factors related to pressure ulcers as discussed in Chapter 48 of the Fundamentals of Nursing. Improve your understanding and readiness for the clinical application of wound care principles.