Wounds and ulcers

Location of greatest risk for ulcers

Over bony prominences

Stage 1 pressure ulcer

• Skin is intact with non-Blanchable redness

• Area may be soft or firm or cooler or warmer compared to surrounding skin

• May be painful or itchy

Stage 2 pressure ulcer.

• involves dermis with partial thickness loss

• Shallow open ulcer that’s shiny or dry

• Can also be a blister that is either intact or open

• Wound is red/pink with no slough or bruising

Stage 3 pressure ulcer

• full thickness loss with possible fat visible

• Bone, tendon, muscle are not exposed

• Depth can vary based on location

Stage 4 pressure ulcer

• Full thickness tissue loss with bone, muscle, ottr tendon visible or palpable

• Depth can vary based on location

Wound evaluation

• Visually inspect wound

• Measure with disposable tape measure

• Use sterile cotton swab to check for tunneling

• Document color

• Take circumference dismally and proximally to the wound

• Administer analogue pain scale

• Administer COPM

• Change dressings daily and not progress

Persons at high risk for wounds should be evaluated

Every 12 hours

The most effective intervention for all wound types

Prevention

Medicaid categories for pressure reducing devices

Group 1: cushions or mattresses that use non-electrical means to distribute pressure

Group 2: dynamic electric powered devices for persons with full thickness ulcers or those t moderate to high risk

Group 3: dynamic electric powered devices for persons with no healing full thickness ulcers

Positioning and weigh shifting techniques

• Full push-ups,

• Lateral leans

• Forward leans

• Wheelchair tilt recline options

How often should weight shifting occur

Every 30 minutes for 30 seconds or every 60 inures for 60 seconds

Integrate weight shifting into daily activities

Where to check when looking for pressure sores

• scapula

• Elbows

• Ischia

• Sacrum/coccyx

• Trochanters

• Heels/ankles

• Knees