Pressure Points, Skin Integrity, and Ulcer Stages

Pressure Points

areas that bear majority of your body's weight

Bone Prominences

Areas where the bone lies close to the skin

• Cheeks, chin, elbows, knees, ankle, heel, etc

Shearing

Rubbing or friction from skin moving one way and underneath it.

• Patient laying on bed shearing to get comfortable. Resulting in bed sores, pressure injuries, etc.

• Patient is in a fixed position and skin is rubbing on sheets b/c of unrelieved pressure. (Turn every 2 hrs on bed. If wheel chair bound, shift every 15 mins only if they are independent. If not, CNA helps shift every 1 hr)

Only the lateral position doesn’t cause ulcers

Necrosis/Gangrene

Lack of oxygen and nutrients=cells die
- Result: Black Skin
- Most commonly seen in diabetic patients who's feet have been restriced blood flow cuz of pressure points = no nutrients + nerve damage. This leads to unrecoginzed blisters, cuts, or pressure sores.

Function of skin

• Defense against microorganisms

• Helps excrete water and waste (sweat -->retains water=swelling)

• Produces vitmain D from sunlight

Aging

• Less elastic (turgor) and becomes thinner.

• You feel colder.

• Decrease skin tugor/elasticity meaning your dehydration

• Nails become hard and brittle

Systemic Infection

whole body involved (circulatory system)

Local infection

in a body part

Stage 1 of Ulcer

Redness unrelieved

• Test: Press on the skin. If skin blanches = Okay (red turning white)

Stage 2 of Ulcer

Blister/ Open sore

Stage 3 of Ulcer

Crater (bowl shaped surface)

Stage 4 of Ulcer

Damaged muscle or bone

• If patient reaches stage 4, patient will never heal past stage 2