ACTIVE LEARNING TEMPLATE: System Disorder
STUDENT NAME DISORDER/DISEASE PROCESS preSSure uIcer
REVIEW MODULE CHAPTER
Alterations in Health (Diagnosis) localized damage to the skin/ underlying soft tissue
Pathophysiology Related to Client Problem impaired skin capillary!pressure!results in local tissue anoxia.
Health Promotion and Disease Prevention
rotate positions frequently
ASSESSMENT
SAFETY CONSIDERATIONS
Risk Factors
Expected Findings Shiny, erythematous superficial lesion (early)
Possibility of infection can lead to sepsis or loss of limbs
Poor nutrition, decreased lean body mass, Diabetes mellitus, Decreased mobility, immobility, or!paralysis
Laboratory Tests
Diagnostic Procedures Wound assessment
Wound culture and sensitivity testing, CBC and differential, white blood cell, ESR, total serum protein
PATIENT-CENTERED CARE
Complications
Nursing Care
Medications
Client Education Teach about wound care, prevention of pressure ulcers, importance of checking feet for ulcers
Secondary bacterial infection; growth of resistant organisms Septic shock Sinus tracts gangrene cellulitis
Shoes Braden scale to Intermatic identify risk for pressure pointman's, injury, relieve pressure on antibiotics, the affected side topical anti- microbial's, NSAIDs
Therapeutic Procedures
Interprofessional Care Dietitian surgical debridement, direct closure, flap reconstruction, skin grafting
Skin integrity, pain level went to assessment, alginate dressing, pressure reducing device application
ACTIVE LEARNING TEMPLATES
THERAPEUTIC PROCEDURE A