Skin Integrity and Wound Care 2019-2020 PDF

Tishk International University Nursing Faculty Nursing Department Fundamental of Nursing Skin Integrity and Wound Care First Grade – Spring Semester 2019-2020 Instructor: Halmat Authman Rasheed PRESSURE ULCERS Pressure ulcers consist of injury to the skin and/or underlying tissue, usually over a bon...

Tishk International University Nursing Faculty Nursing Department Fundamental of Nursing Skin Integrity and Wound Care First Grade – Spring Semester 2019-2020 Instructor: Halmat Authman Rasheed PRESSURE ULCERS Pressure ulcers consist of injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of force alone or in combination with movement. Pressure ulcers were previously called decubitus ulcers , pressure sores , or bedsores. Etiology of Pressure Ulcers like: anemia Ischemia After the skin has been compressed, it appears pale, as if the blood had been squeezed out of it. When pressure is relieved, the skin takes on a bright red flush, called reactive hyperemia The flush is due to vasodilation , Reactive hyperemia usually lasts one half to three quarters as long as the duration of impeded blood flow to the area. If the redness disappears in that time, no tissue damage is anticipated. If, however, the redness does not disappear, then tissue damage has occurred Risk Factors FRICTION AND SHEARING: Friction is a force acting parallel to the skin surface. For example, sheets rubbing against skin create friction. Shearing force is a combination of friction and pressure. It occurs commonly when a client assumes a sitting position in bed. In this position, the body tends to slide downward toward the foot of the bed. IMMOBILITY Immobility refers to a reduction in the amount and control of movement a person has. paralysis, extreme weakness, pain, or any cause of decreased activity can hinder a person’s ability to change positions independently INADEQUATE NUTRITION Prolonged inadequate nutrition causes weight loss, muscle atrophy, and the loss of subcutaneous tissue. These three conditions reduce the amount of padding between the skin and the bones. Inadequate intake of protein, carbohydrates, fluids, zinc, and vitamin C contributes to pressure ulcer formation. Hypoproteinemia (abnormally low protein content in the blood),