Pressure Injury stage 2 ATI System Disorder PDF

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Summary

ATI Active learning Template on Stage 2 specific pressure injuries...

Description

ACTIVE LEARNING TEMPLATE:

System Disorder

ST UDENT NAME _____________________________________

Pressure Injury stage 2 DISORDER/DISEASE PROCESS __________________________________________________________

Alterations in Health (Diagnosis)

REVIEW MODULE CHAPTER ___________

Pathophysiology Related to Client Problem Soft tissue blood flow is impaired due to patients skeleton pressing against surface through skin, adipose tissue and muscle.

Ishemic destruction of soft tissue r/t periods of inactivity and pressure

Health Promotion and Disease Prevention Frequent repositioning of patient, support of boney prominences, encouraging out of bed, proper nutrician, exercise.

ASSESSMENT

SAFETY CONSIDERATIONS

Risk Factors

Expected Findings

Immobility, Inactivity, altered mental status, malnurishment, incontinence, diabetes mellitis, impaired sensory preception, PVD, Friction, prolongd contact with medical devices.

Laboratory Tests Albumin serum protein BMP CBC Culture of wound Blood cultures

Stage-2: Localized pain and tenderness. Surface of skin is not intact and dermis is exposed. Apperance of an abrasion or open blister with red wound bed. No exposed adipose of musclulature.

Diagnostic Procedures - Evaluate w/ Braden Scale - Photographic monitoring - Measurements with wound card and tape - Staging of wound

PATIENT-CENTERED CARE

Nursing Care Prevent pressure on injury, wound care, cover wound to protect tissue, monitor for infection, administer or apply medications per orders, reposition patient frequently.

Therapeutic Procedures support tissue, nutritional support, wound care and dressing, physical therapy, whirlpool, alternating pressure hospital bed

ACTIVE LEARNING TEMPLATES

- avoid prolong inactivity - cushionn boney prominences - Coushion contact points w/ medical equipment - Use off loading boots - Maintain skin clean & dry - Quick care for incontinence - Head to toe with skin assessment at the start of shift

Complications Medications - Medisorb A - Medisorb P - Medisorb P plus - Medisorb H - Medisorb F - Medisorb G - Bacitracin - Bactroban - Iodosorb - Acticoat dressing - Polysporin - Silvadene - Chlorpactin - Hydrocolloid dressings

Client Education High protein diet, proper hydration, reposition frequently, use cushions on boney prominences. care of the wound to prevent infection, prevent damage to wound bed.

- Cellulitis - bone infection - sepsis - Cancer - Myositis - Tendonitis

Interprofessional Care Dietitian, Physical therapy, home health nursing, wound care, primary care

THERAPEUTIC PROCEDURE

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