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Risk Factors for Pressure Ulcers

Friction and Shearing
Inadequate Nutrition
Fecal and urinary incontinence
Decr. mental status
Diminished sensation
Excessive body heat

Risk Assessment Tools for Pressure Ulcers

Braden Scale for Predicting Pressure Sore Risk
Norton's Pressure Area Risk Assessment Form Scale

*Need consistency for trending and measuring


2 Layers: The Epidermis and Dermis

Pressure Ulcer (PU) Stage I

nonblanchable erythema

PU Stage II

Partial thickness skin loss

PU Stage III

Full thickness skin loss involving damage/necrosis to subcutaneous tissue

PU Stage IV

Full thickness skin loss + damage/necrosis to muscle, bone, or supporting structures

Reactive Hyperemia

A bright red flush on the skin occurring after pressure is relieved (illustrates blood is still flowing to this area - no ischemia)

Partial Thickness

Confined to teh skin, that is, the dermis and epidermis; heal by regeneration

Full Thickness

Involving the dermis, epidermis, and subcutaneous tissue, and possibly muscle and bone; require connective tissue repair.

Primary Intention Healing

Tissue surface approximated

Secondary Intention Healing

(inside -> out)
Edges cannot be approximated
Large tissue loss
Scarring is greater
Takes longer
Higher susceptibility to infection (open wound)

Tertiary Intention Healing

(Delayed primary intention)

Initially left open 3-5 days
Normally to to drainage or infection

Phases of Wound Healing

Proliferative (collagen synth and granulation tissue formation)
Maturation (organization/remodeling, scar stronger)

Wound Exudate

Serous (watery)
Purulent (yellow, pus)
Sanguineous (bloody)

Mixed Exudate

Serosanguineous (watery + blood)
Purosanguineous (pus + blood)

How to measure Pressure Ulcer Depth

Parallel swabs used to measure wound depth

Obtain Wound Specimen from...

From base of the wound
*think in class they said, irrigate, then obtain specimen from inside granulated tissue

Preventing Pressure Ulcers

Reassess clients risk for all clients DAILY
Semi Fowlers preferred 45-60
Turn q.2h

Skin Cleansing Agents

Use "Mild" agents

Treating Pressure Ulcer

Never use alcohol or hydrogen peroxide
These are cytotoxic (they kill cells)
ROM exercise
Provide devices to minimize pressure areas

RYB Color Guide Wound Care

Red = protect and cover
Yellow = cleanse
Black = Debride (remove the dead black necrotic flesh.. yum)

Gallant Salute

Peter Wesson

Wound Dressing for Pressure Ulcers

Transparent Film
Impregnated Nonadherent
Clear absorbent acrylic
Polyurethane foam

Montgomery Straps

Tie Tapes - used to secure large dressing that require frequent changing - the tape has ties on it, so you don't have to remove and reapply tape a bunch (risk tearing the skin)


Incr. capillary permeability
Incr. cellular metabolism
Incr. inflammation
Sedative effect

Use Heat For...

Joint stiffness from arthritis
Low back pain


Decr. capillary permeability
Decr. cellular metabolism
Slows bacterial growth
Decr. inflammation
Local anesthetic effect

Use Cold for...

Post-injury swelling and bleeding (contusions?)

Rebound Phenomenon

Heat: 30-30 min (more = bad)
Cold: only until 15 degrees Celsius (60F)

When cleaning a drain (e.g., penrose)

Use circular movements.
Start around the drain and work your way out.
Precut gauze goes on afterwards


Hydrocolloid dressings protect shallow ulcers and maintain an appropriate healing environment


are used for wounds with significant drainage

Braden Scale

Total of 23 Points.
Below 18 points is at risk.

Nortons Scale

Total of 24 Points.
15 or 16 are scores that indicate risk.

Granulation Tissue

As the capillary network develops, the tissue becomes a translucent red color. The tissue, called granulation tissue, is fragile and bleeds easily.

Cleaning sutures

Clean midpoint to outwards. Top to bottom. (book)


Partial or total rupturing of a sutured wound


The protrusion of the internal viscera through an incision

Anti-embolic Hose

Compression hose.
designed to increase blood circulation
Tighter at ankle, push blood back to the heart.

Delegation of Wound Care

You don't delegate wound care? Correct me on fb if this is wrong pls.

Care of contusions


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