occur in 1/4 of american adults over age 65

cost about 750 million a year

• difficult to treat, result in pain
• increase hospital stay
• caused by insufficient circulation secondary to unrelieved pressure
• major risk in the elderly

• this is the most important step to establish the nursing care plan
• need to assess the whole person not just the ulcer
• looking for risk factors to delayed healing and ulcer formation

• assess ability to move independently
• assess shearing force, sliding down in bed and repostioning
• assess friction, espcially elbows and heels
• assesss fever

Wound healing by promary intention

inflammatory phase (reaction)

• bodys natural reaction. lasts about 3 days
• cells involved, platelets clotting form fibrin
• fibroblasts make collagen
• epithelial cells form epithelial tissue

Wound healing by primary intention

proliferative phase (regeneration)

• Lasts 3-24 days
• cells involved, fibroblasts continue to make collagen.
• closes wound by epithelization
• need vitamin B and C plus amino acids

Wound Healing by primary intention

Maturation (remodeling)

• remodeling of collagen fibers
• may take more than a year. depends on depth of incision.

• total or partial separation of wound layers
  may be made intentionally to drain an infected incision
• risk factors are nutritional status, infection, obesity

• total separtation of wound layers with protrusino of visceral organs
• requires surgical repair keep patient NPO

• abnomal passage between 2 organs or between an organ and the outside of the body
• usually results in delayed wound healing or may need surgical repair

• impaired skin integrity
• imbalanced nutrition
• impaired physcial mobility
• infection
• pain
• anxiety

• maintain intact skin
• experience a reduction in size of skin lesion
• be free of signs and symptoms of infection
• report any altered sensation or pain at site of skin impairment

• assessment of skin
• hygiene
• postioning
• support surfaces
• nutrition/hydration

• persistent locilzed area of skin redness, usually over a bony prominence.
• may be difficult to detect in individuals with dark skin tones
• no break in skin
• cover with steril transparent dressing such as tegaderm
• heals in 1-2 weeks

• partical thickness loss of skin layers which presents as an abrasion, blister
• reversible of detected early
• apply transparent dressing or hydrocolloid dressing
• these ulcers take 2-4 months to heal

• full thickness loss of skin which presents as a deep crater with subcutaneous tissue exposure
• usually irrigated
• can apply transparent or hydrocolloid dressing

• Full thickness loss of skin and subcutaneous tissue exposing muscle and or bone
• treat with debridement
• IV antibiotics
• Skin grafts
• wet/dry dressing
• take months to years to heal

Full thickness tissue loss in which the base of the ulcer is covered by slough

until enough slough or eschar is removed to expose the base of the wound, the true depth and therefore stage cannon be determine

• clindamycin or gentamycin may be ordered
• vitamin C
• antibiotic prophylaxis
• a two week trial of topical antimicrobials should be used

• best and most effective nonsurgical technilogies avalable for healing both acute and chronic wounds
• accelerates wound healing by promoting the formation of granulation tissue.

immobility

Metabolic

effect: nitrogen loss relfects decreased muslce mass, decreased serum protein results in change in osmotic pressure.

interventions: assess, do BUN check diet

Immobility

Respiratory

effect: decrease lung expansion, pooling of secretion resulting in pneumonia, decrease gas exchange

Interventions: Vital signs, lung sounds, sperometer

immobility

Cardiovascular

Effect: othostatic hypotension, decrease bp reflected by dizziness, increased cardiac workload

Interventions: Heparin, SCDs

Immobility

Musculoskeletal

Effect: decreased muscle mass resulting in loss of endurance, demineralization of bones, decrease calcium

Interventions: ROM

Immobility

Integumentary

effects: Aged skin is usually dry and easily cracks, decubitus ulcers, candida infections, check nails also

Interventions: assess- when doing bath or shower

immobility

Elimination

effects: urinary retention because of incompelete emptying resulting in UTI, constipation due to increase GI motility

interventions: assess I and O, creatinine, bowel sounds

immobility

Psychosocial

Effects: depression or behavioral changes, decreased coping abilites, fear of falling, developmental changes involving self concept and role changes

interventions: building relationships