Shear: adjacent parts of body slide past each other,
tearing blood vessels
Friction: rubbing against a surface causing abrasion, blistering
Assess Risks: moisture; can patient change body position; look for initial signs of ulcers
Make a plan, educate patient, care-givers and family.
Legal Liability: Negligence = failing to provide proper care, or providing improper care.
Malpractice: negligence by a professional.
To prove negligence, need to prove all four: Duty; Breach; Causation and Damage.
Staging: Partial-thickness vs. Full-thickness
4 Stages of Pressure Ulcer Development:
'Stage I': intact skin, see a line of erythema where finger touches.
'Stage II': loss of epidermis or dermis or both; epithelium separated
from dermis (blistering).
'Stage III': full-thickness; skin loss; undermining; necrotic tissue.
'Stage IV': damage down to subcutaneous tissue or fascia or bone.
When staging, report 'depth'; 'amount of healing (granulation tissue'; 'eschar formation (necrotic tissue)'.
It will not heal by reverse staging.
A partial-thickness ulcer will resurface by re-epithelializing).
A full-thickness ulcer will undergo tissue repair with inflammation; contraction;
collagen remodeling; granulation.
Assessment: look for location (over boney prominence); width, depth, length; sinus tracts;
undermining; exudate; color; odor; percentage of granulation tissue; percent necrosis;
inspect periwound area.
Treatment: pressure relief (special mattress; foam cushions);
wound treatment: cleaning (DO NOT use iodine,
hydrogen peroxide or alcohol. These inhibit cell growth.)
Debridement of necrotic tissue.