Assessment of Decubitus Wounds

ASSESSMENT OF DECUBITUS WOUNDS Understanding Decubitus is local tissue necrosis that tendssurfaces to occurforwhen soft tissueofistime. compressed between bony prominences and external a long period Localoxygen tissue and microcirculation disturbances occur and result in tissue hypoxia. Tissues obtain nutrients and remove metabolic waste through the blood.orSeveral factors thatcirculation, interfere with this process will affect cell metabolism by reducing eliminating tissue causing tissue ischemia. Tissue ischemia is the local absence of blood or decreased blood flow due to Pallor mechanical obstruction. Decreased blood flow causes areas of the body to become pale. is seen when there is a reddish color in light-skinned patients. Pallor does not occur in patients with dark pigmented skin. Factors influencing the formation of decubitus sores Disruption of skin integrity thatincrease occurs inthedecubitus isrisk a result of pressure. However, there are additional factors that can patient's of developing further pressure sores. According Potter & Perry (2005) there are 10 factors that influence the formation of decubitus wounds,to including: a. Friction, b. Friction, c. Humidity, d. poor nutrition, e. Anemia, f. Infection, g. Fever, h. Peripheral circulation disorders, i. Obesity, j. Kakesia, and k. Age. Pathogenesis of Decubitus Wounds a. The three elements that are the basis for decubitus are: b. The intensity of pressure and the pressure that closes the capillaries c. Duration and magnitude of pressure d. Network tolerance Classification of Decubitus Wounds a. b. c. There are degrees in the classification of decubitus wounds, namely: Grade I: Non-blanching intact enlarged skin wound lesions. Colorless, warm, or tougherythema skin mayonalso be skin, an indicator Grade II: Lossis superficial of partial thickness of thelooks skin including the epidermis andordermis. The wound and clinically like an abrasion, abrasion, shallow hole. d. Grade III: Full-thickness lossnot of skin including subcutaneous orThe necrotic tissue that may extend downward but beyond the underlying fascia. wound clinically looks like a deep hole with or without damage to the surrounding tissue. e. Grade IV:toFullmuscles, thickness lossorofsupporting skin with extensive destruction, tissuetonecrosis; or damage bones structures such as damage epidermis, dermis, subcutaneous tissue, muscles and joint capsules Place of occurrence of Decubitus Wounds a. Some oflateral the most commongreater placestrocone, where decubitus occurs are theAreas sacrum, heels, elbows, malleolus, and ischial tuberostis. of the body that are often affected by decubitus sores are: b. Inandpatients heels. in the supine position: in the back of the head, shoulder blades, buttocks c. Inshoulders, patients elbows, in a tiltedgroin position: thethe headtop(especially area, the ankleedge skinofand of the toes.the earlobe), d. In patients in the prone position: forehead, upper arms, ribs and knees Assessment of Decubitus Wounds Continuous baseline assessment data provides important information on the of patient's skin integrity and increased risk of developing pressure ulcers. The assessment decubitus cannot betheseparated from the skin becauseulcer decubitus hashasmany etiological factors. Therefore, initial assessment of pressure patients several dimensions.Assessment of the risk of pressure ulcers must be carried out systematically: Identify risks occurring to patients: a. Paralysis or immobilization caused by devices that limit the patient's movement. b. Sensory loss c. Circulation disorders d. Decreased level of consciousness, sedation, or anesthesia e. Friction, friction f. Moisture: incontinence, sweat, wound drainage and vomiting g. Malnutrition h. Anemia i. Infection j. Obesity k. Kakesia l. Hydration: edema or dehydration m. Elderly n. Presence of decubitus Assess theareas: condition of the skin around the area that is experiencing pressure in the following a. Reactive hireremia b. Pale color c. Induration d. Pale and mottled e. Loss of surface skin layers f. Ulcers, blisters or spots 1. Assess areas of the patient's body that have the potential to experience pressure: a. Nostril b. Tongue, lips c. Intravenous insertion site d. Drainage hose e. Foley catheter 2. Observe the patient's preferred position when in bed or chair 3. Observe mobilization and the patient's ability to perform and assist in changing positions. Determine the risk value: a. Norton Scale b. Gonsell Scale c. Barden Scale 4. Monitor the length of time the area is red 5.amount, Obtainhemoglobin nutritional assessment serum albumin amount, total protein amount, anddata idealwhich bodyincludes weight presentation 6. Assess patient and family understanding of the risk of pressure ulcer