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Venous Stasis Ulcers |
Higher-than-normal blood pressure within the leg veins resulting in pathophysiologic changes. including varicosities, edema, hemosiderin staining.
Valves in the veins are unable to perform function. This results in fluid pooling and breaking open the skin and creating an ulcer. Nursing Interventions: Elevate lower extremities using pillows, etc... Compression needs to be ordered by a provider. Application should start at the foot and work way up. |
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A wound which results from inadequate arterial blood supply or flow. Frequently, these wounds are located on the distal extremities. These Ulcers are very Dry. There is rarely exudate. They also have a punched out appearance as if a punch biopsy was taken.
Nursing Intervention: Increase blood flow to lower extremities. Do not elevate legs and Do not apply compression. Patients usually feel better when they have their legs dangle down. in extreme situations amputations are necessary. To diagnosis an arterial ulcer an Arterial Doppler study with Ankle-Brachial Index. Patient will experience intermittent claudication (cramping pain). |
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This is also known as a yeast infection. This occurs when the skin is exposed to too much moisture. This is a fungal infection.
This can occur in folds of the skin such as under breasts, abdominal pannus, armpits, etc... Nursing Interventions: Keeping the area clean and dry. Also keeping a fabric wick to remove moisture. InterDry (not advertising) is an antimicrobial cloth with silver. |
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Pressure Ulcers |
Stage 1: Non blanching red or pink tissue.
Stage 2: Loss of the epidermis (partial thickness) and loss of some of the Dermis Stage 3: Loss of the Dermis (Full-Thickness) and exposure of adipose tissue. Stage 4: Exposure of bone, muscle, tendon. Loss of Epidermis, Dermis, and adipose tissue. Deep Tissue Injury: Localized are of discolored skin that is purple or maroon in color. Non-blanching with intact skin and feels boggy. Unstageable: Full thickness loss covered with eschar or non-viable tissue. Once staged: a pressure ulcer continues with that staging forever. Documentation should be stated as "healing" or "non-healing" Pressure Ulcer Stage ___. Nursing Interventions: Offload pressure to area. Many facilities have protocols for special offloading mattresses. Refer to wound care specialist. |
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Diabetic Ulcers |
These ulcers can occur in multiple ways.
Shoes not correctly fitting, socks with seams rubbing on feet, and not wearing socks with shoes inside the house. Daily feet inspections should be conducted. Uncontrolled Hyperglycemia is a huge reason wounds occur. Diabetic peripheral neuropathy will contribute to an ulcer not receiving attention because there is no sensation. Shoes should not have a pointed toe but should be rounded. Hot water bottles of electrical blankets should not be used on the feet. Nursing Interventions: Offloading pressure on the feet or else wound will never heal. Monofilament test is a noninvasive study and can be performed anytime there is suspicion of Diabetic Peripheral Neuropathy. Educate about controlling blood sugars. Refer to dietitian. |
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Skin Tears |
Traumatic peeling away of the epidermis from the dermis. The older adult can receive many skin tears by bumping into doors, beds, etc...
Nursing Interventions: long sleeve shirts, sweaters, or removable sleeves can help prevent further damage. Apply a non-adherent dressing with a written arrow on bandage in the direction bandage should be removed. |