CHAPTER 10 Integumentary System^409
- Monitor for temperature, enlarging area of redness, increase in drainage.
- Explain to the patient how to prevent openings in the skin by using proper skin
care interventions. - Monitor feet and legs daily for cracks, fissures.
- Use care in trimming nails, or visit podiatrist.
- Use moisturizing lotions regularly.
Pressure Ulcers
WHAT WENT WRONG?
A pressure ulcer starts on the skin and often progresses to deeper tissue; it is caused
by impaired circulation to the tissue from pressure over a period of time. Without
adequate blood flow and the nutrition it brings, the tissue will die. Those often
affected are confined to a wheelchair or bed, and unable to move themselves, not
reducing the pressure frequently enough. It can take as little as a few hours in one
position for a stage one pressure ulcer to develop. The usual sites of pressure
ulcers, or bedsores, are on bony prominences, such as the buttocks, sacrum, heels,
knees, and hips. Friction from linens can impair the integrity of the skin as can the
shear force, when the skin moves in one direction and the deeper structures don’t
move. Assessment tools are available to predict the risk of pressure ulcers devel-
oping. A commonly used scale is the Braden scale which includes such criteria as
friction, the nutritional status of the patient, mobility and activity levels, moisture
exposure of the skin and any limitations of sensory perception.
PROGNOSIS
Unfortunately, prognosis is poor. The very factors that caused the pressure ulcer
are the same factors that interfere with healing. Resolution often is very involved
and slow. Setbacks are common, such as wound infection, cellulitis, and sepsis,
which can lead to death.
HALLMARK SIGNS AND SYMPTOMS
- Stage I:
- Firm warm areas of skin from poor circulation
- Spongy, reddened tissue from increased pressure
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