Try: Pressure ulcers are localized areas of tissue ischemia or skin breakdown they are caused when soft tissue the skin is compressed between a bony prominence like a hip and an external surface like a mattress for a prolonged period of time if left untreated these ulcers progress through increasingly destructive stages eventually producing necrosis or tissue death a staging system measures destruction by classifying wounds according to the tissue layers involved to carefully evaluate the amount of tissue damage other factors such as undermining slough eschar and sinus tract development must be considered definitions by the national pressure ulcer advisory panel npuap stage i an observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following skin temperature warmth or coolness tissue consistency firm or boggy feel and or sensation pain itching the ulcer appears as a defined area of persistent redness in lightly pigmented skin whereas in darker skin tones the ulcer may appear with persistent red blue or purple hues stage ii partial loss of skin thickness involving epidermis and or dermis the ulcer is superficial and presents clinically appears as an abrasion blister or shallow crater stage iii full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through the underlying fascia the ulcer presents clinically as a deep crater with or without undermining adjacent tissue stage iv full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle bone or supporting structures e g tendon joint capsule note undermining and sinus tracts may also be associated with stage iv pressure ulcers a healing wound is in the process of reconstruction the base of a healing stage iii or stage iv wound is filled with granulation tissue so as a stage iii pressure ulcer heals it must be carefully observed and protected to prevent re-occurrence primary causes and effects of skin breakdown pressure unrelieved pressure is the primary cause of pressure ulcers and skin breakdown the effects of excessive pressure on soft tissue depend on the intensity of the pressure how heavy the patient is for example how long pressure is applied how well the tissues tolerate pressure a key variable is capillary closing pressure the pressure at which small blood vessels close this level of pressure can vary dramatically from patient to patient shear is caused by tissue layers sliding against each other this can cause disruption or angulation of blood vessels usually at the fascia level shearing forces account for the high incidence of sacral ulcers when a patient patient’s head is elevated the skeletal frame slides toward the foot of the bed while the sacral skin adhere by friction to the bed linen sliding produces stretching and angulation of the arteries that supply the skin f riction is surface skin damage caused by skin rubbing against another surface an example is sliding a patient up in bed the skin rubbing against the sheet causes friction and the resulting burn or abrasion exposes the skin to bacterial invasion and infection treatment planning and intervention recognizing and relieving pressure will help prevent skin breakdown reduce the healing time of existing ulcers lower the cost of treatment reduce pain and discomfort to the patient pressure reducing devices these devices offer an effective way to reduce interface pressure below what is encountered with a standard mattress they cannot provide pressures consistently less than 25-32 mm hg so they may have to be used with a turning schedule examples of such devices include foam mattresses gel water mattresses static air mattresses foam overlays pressure relief devices these consistently reduce pressure below 25-32 mm hg examples include low air-loss therapy beds alternating pressure mattresses dynamic mattress systems air fluidized therapy systems corrective steps to reduce the effects of shearing the plan of care should include the following specific nursing steps do not elevate the head of the bed for prolonged periods use care in placing and removing bed pans use patient handling techniques and tools to reduce friction such as heel protectors an over-bed trapeze transparent dressings and a mattress with a low friction covering methods to protect the skin from excessive moisture should also be included in the plan of care some helpful supplies include skin cleansers moisturizers lubricating sprays and ointments ointment barriers skin sealants incontinence devices information references "wound care help" 2008 by sherman oaks medical supplies available at www shermanoaksmedical com
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Categories: Sage, Topic, Medical Physical, Mobility, Needs Some Assistance, Needs Much Assistance, Immobile
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Keywords: Wound pressure ulcers pressure sores skin sheering mattress skin breakdown
*This information is listed as a Fact Sheet and is not explicitly medically licensed