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What areas on the body are at risk for this?

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What areas on the body are at risk for this?

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damage to the skin due to pressure in that area as a result of ischemia.

Wound that is suffocated due to pressure.

Bony prominences - heels, elbows, lower back, butt, back of the head, knees, ears

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mobility issues

bedridden

obesity

diabetes

poor circulation

poor nutrition

old age

inc. of bowel and bladder

smokers

prior wounds

skin elasticity

moisture

immobile

poor repositioning

use of oxygen, and other accessories

documentation - poor

poor hygiene

tissue damage

falls

injuries

braces

......

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neurological

why did she fall

support system

why on the floor 10 hrs

why did no one check on her

blood glucose

diet - who and what

last time ate or drank

how deep is the ulcer

inc. b/b

arthritis - not moving and pain

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measure it - paper ruler, disposable, and measure in cm. measure the largest distance, LxWxD, use a clock approach, and measure all aspects of the wound

premedicate - assess pain

odor

drainage - serous, sanguineous, serosang., purulent

how much drainage - saturation of dressing, weigh the dressing, and or small, med, large, copious, and ...

can she feel the wound

any swelling

temp of the wound

ask her how long - new or related to fall

any previous issues

SDH - etoh, smoking,

mobility - devices

diet - and what she ate drank

LOC - AOx___

Inc. B/B

medications - HTN, diuretics, and ....

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Ph

glucose or fingerstick BG

K+--> check deficient for heart, is there an underlying issue of the fall or cause,

NA+

Chl-

mg and phos --> bone health

protein (albumin) --> helps with healing

BUN and Cr --> since she was there for 10 hrs - retention and AKI,

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inflammation

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Liver and check the liver enzymes

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WBC - could be high due to infection and stress, or is there an issue that caused the fall

H/H

Plt

RBC

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? and that is why she fell

ph

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check the body for erythema areas and ecchymosis areas

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check the body for erythema areas and ecchymosis areas

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repo q 2 hrs

elevate the area - on pillow

wound - tx - OTA, keep it clean and dry, barrier cream (skin won't dry out, healing ointment (zinc, Vit D)

Drsg - Mediplex, transparent dressing (you can see it)

diet - fluids, protein, Vit E., Vit C., Vit A., Zinc, folic acid, iron, (CAPEZ); Kcal - 15-35 per Kg;

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some the same - repo, diet, and a dressing

Dressing -

Wet - dry (pros (mechanical) and cons to this - sticks to skin and wound and to the live tissues -

Foam - provide cushion to the wound, there are thin to thick foams, absorbs the exudate, change it about every day to two days

cons - air, it could cause the wound to get macerated, can't see through it.

Hydrocolloid - they keep it moist and has healing agents in it (collogen and water) - autolytic debridement - Cons - DO NOT use for high drainage wounds and necrotic wounds

Hydrogel - cooling effect, hydrates wound, NOT use for high drainage wounds

Transparent film

Vit D and zinc (barrier cream)

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dressing -

alginate (silver) dressing - seaweed dressing to dry and absorb the excess drainage.

foam

hydrocolloid

hydrogel

heal boots

cradle

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honey - these are wonderful for healing

alovera

and then all the others.

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fish - salmon, lean proteins, leafy greens, avocado, omega 3, fruit, carrots,