N213: Health Differences Across the Life Span 3

N213: Health Differences Across the Lifespan 3 Study Guide • Moisture/drainage Signs and symptoms of stage three pressure ulcers: • Ulcerations • Necrosis (black crust) • Tunneling • Crater into muscle tissue Signs and symptoms of stage four pressure ulcers: • Severe, foul smelling purulent discharge • Nursing interventions for pressure ulcers: • Keep patient off the affected side, prop with pillows, and turn every two hours; always use a draw sheet to pull patient up in bed to avoid shearing • Keep area clean and dry, avoid wrinkles in sheets, and change soiled linens promptly • Treat ulcers according to stage: o Stage 1 pressure ulcers: Use lubricants, clear dressings, and avoid pressure to the site o Stage 2 pressure ulcers: Continue above and add cleansing with normal saline or wound cleanser o Stage 3 pressure ulcers: Treat any infection with antibiotics, debride necrotic tissue mechanically or chemically, and cleanse/use of dressing o Stage 4 pressure ulcers: Wound may need to be packed with wet to dry materials while continuing above treatments; skin grafting and surgical debridement may be necessary • Apply vacuum assisted closer and perform related wound care per MDorders • Use hyperbaric oxygen therapy to provide 100% oxygen to wound site per MDorders • Correct nutritional deficiencies, such as protein, calories, and vitamin C; fluids need to be in excess of 2,000 ml daily unless the patient is on a fluid restriction • Discourage use of anti-inflammatorymedications • Do not use harsh soaps, lotions, or alcohol • Do not rub or massage affected areas • Change incontinence products promptly after soiling • Do not elevate the head of the bed more than 30 degrees to prevent pressure • Assist with range of motion exercises • Use a jell mattress or airflowmattresses when possible to reduce pressure to sensitive areas • Monitor the wound for signs of infection: redness, foul odor, edema, or drainage • Monitor vital signs for signs of infection ©2017 Achieve Test Prep Page 144 of 204 • Edema Full thickness tissue loss to the bone • Infection