Integumentary System, PN 124


Causes

- chronic deep vein insufficiency


- delay of venous blood returning to the central circulation



-severe varicose veins, burns, trauma, sickle cell anemia, diabetes, neurogenic disorders and heredity


-Dry/rough looking skin


-Hard to the touch
-Loss of body hair


-Ulcers begin as small, tender, inflamed
-Edema around the ulcer


-Occasional purulent drainage
-Slow to heal


Subjective Data

-Severity of ulcer pain




-worse with the leg dependent
-itching
-duration
-measures to treat the ulcer


Objective Data-

-Size


-location
-appearance




-Color
-both in a dependent and elevated position
-Wound drainage
-color and consistency
-edema
-Surrounding skin appearance
-erythema, induration


Limb elevation
-encourages return of venous blood to the general circulation
-increases arterial blood flow
-to general circulation and lower extremities
-decreased edema.

Compression dressings
-Unna Boot


Infection Control

-aseptic technique with dressing changes
-monitor for signs of infection
-cellulitis

Antibiotics-
-topical (Silvadine cream)
-oral or IV


Debridement

-Removal of necrotic tissue









- Mechanical
-wet to dry dressings
-Chemical
- Enzyme (Santyl, Elase)
-Surgical
-used only if mechanical and chemical means were ineffective
-removal via scalpel of necrotic tissue


Dressings


-Compression
-Unna boot, Ace bandages, TED socks

Pain Management


-Elevate legs, analgesics, topical anesthetics


Nutrition
-Protein, Vitamin A, Vitamin c, Zinc

(Bedsores/decubitus ulcers)
Causes
-Pressure on the skin
-collapse of capillaries
-ischemia/redness-1 hour
-tissue necrosis-after 2 hours
-boney prominences
-


Shearing

-Force exerted against the skin


-movement or repositioning
-Stretches and tears the blood vessels,


-reducing blood flow
-necrosis develops



Friction

_the force of 2 surfaces moving across on


 another
_the rubbing of skin against the sheets
_removes superficial skin
_increases the risk of skin breakdown







Stage I

- Non-blanchable erythema of intact skin


Stage II Pressure ulcer

-Partial thickness skin loss

-epidermis, dermis or both.
-Ulcer is superficial
-abrasion, blister or shallow crater


Stage III Ulcer

-Full thickness skin loss
-damage or necrosis to the subcutaneous tissue.



-May extend down to, but not through the underlying fascia.
-Deep crater with/without undermining of the adjacent tissue.


Stage IV Ulcer

-Full thickness skin loss
-extensive bone destruction, tissue necrosis, or damage to muscle, bone, or supporting structures
-Undermining and sinus tracts









Braden Assessment Tool

Norton Pressure Ulcer Scale


Norton Assessment Tool



1. Impaired mobility


-bedbound
-wheelchair bound

-dependent on positioning

2. Moisture



-incontinent of urine and/or feces,
-perspiration
-wound drainage




3. Nutritionally compromised
-underweight
-obese
-poor nutritional status
-poor food/fluid intake
-secondary to poor appetite
-dysphasia
-limited ability to feed themselves.
4. Disease Process
-diabetes
-anemia
-atherosclerosis,
-edema
5. Vitamin and Mineral Deficiencies
-vitamin A, C, E, Zinc





-elderly
-impaired mobility
-poor nutritional status
-altered level of consciousness







-written repositioning/ turning schedule
-30 degree position when side lying
-pillows and foam wedges
-turn sheet to reposition or lift patient in the bed
-encourage patients in wheelchairs to shift their weight every 15 minutes




-inspect the skin daily
-mild cleanser for bathing






-avoid massaging skin over a boney prominence
-moisturizer on the skin
-protective barrier ointment for incontinent patients
-clean the skin at the time of incontinence.







-Egg carton mattress
-Geomatt mattress
-foam overlay mattress
-comparatively inexpensive
-Air overlay mattress
-placed over the hospital bed mattress
-weight redistribution
-Clinitron Bed
-mattress filled with small glass sand particles,
-moisture flows through the mattress




-mattress of air-inflated pillows divided into sections




-pressure can be adjusted in each of the sections according to the client’s needs
-air flow form the mattress to eliminate moisture.





PREVENTION!!!
-most important aspect to be taught to client’s and their caregivers!!
1. Turning, positioning and shifting
-every 2-3 hours- even during the night.
2. Observe skin daily


3. Diet adequate in protein, vitamins, calories and good fluid intake.
4. Notify the health care provider for any changes in the skin.






-Reinforce aggressive turning, positioning and pressure relief.
-Home Health RN
-assess the wound
-instruct the client and/or caregiver
-wound care
-signs of healing vs. deterioration
-homebound clients