Nursing 213

N213: Health Differences Across the Lifespan 3 Study Guide

• Give tetanus booster if needed Expected outcomes for soft tissue trauma: •

Patient verbalizes increased comfort and pain reduction • Wound displays healing and tissue granulation • Wound remains free of infection • Maintains stable vital signs and fluid volume • Maintains adequate tissue perfusion, peripheral pulses, and skin color Pressure Ulcers These skin wounds occur from long-term pressure to one specific area of the body. There could also be multiple pressure ulcers near the bony prominences. Some of these areas include the heels, sacrum, elbows, greater trochanter, ischial tuberosities, and the malleoli. These wounds happen when pressure is placed over the areas, or the area is sheared with movement. Factors that cause wounds are immobility, poor nutrition, age, moisture, poor circulation, incontinence of urine/feces, high blood sugar, obesity, anemia, and poor cognition. Wounds may be at the skin’s surface (superficial) or deep wounds going all the way to the bone. Wounds at the skin’s surface happen when the skin becomes irritated and macerated (pruning), and deep wounds happen due to trauma or lack of circulation to the tissue underneath the skin. Not all deep tissue pressure ulcers can be seen, and by the time the skin opens up, there can be severe damage noted to the underlying tissues. Pressure ulcers need immediate and ongoing treatment to avoid complications which include infection, tissue necrosis, serous fluid loss, and deep wounds that extend to the bone. Direct factors causing pressure ulcers include: • Shearing: This is caused by moving a patient across bed surfaces, making the tissue layers rub against each other. • Moisture: Lying in a moist bed from sweat, urine, or after a bath can macerate skin and begin breakdown. It can also cause bacteria to grow in the area. • Pressure: Lying in the same spot decreases the flow of blood, oxygen, and nutrients to an area of skin. This is most common over the bony prominences and causes capillary pressure, ischemia, edema, and thromboses of blood vessels, which leads to tissuenecrosis. Signs and symptoms of stage one pressure ulcers: • Redness • Erythema • Warmth • Inflammation • Intact skin • Abraded appearance

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