Pressure Ulcers Localized injury to the skin and/or underlying tissue (usually over a bony prominence) as a result of pressure or pressure in combination with

Role of Nursing Personnel Registered Nurse (RN) Assess patients for pressure ulcer risk and develop a plan of care to prevent the development of pressure

Healing Process The final phase of the inflammation process is healing Healing includes two major components: Regeneration Replacement of lost cells and tissues with cells

Nursing and Interprofessional management Nursing Implementation Health Promotion Prevention of injury Adequate nutrition Early recognition of inflammation Immediate treatment Acute Intervention Observation Vital signs Fever

Types of Inflammation Acute Healing occurs in 2 to 3 weeks, usually leaving no residual damage Neutrophils are predominant cell type at site of inflammation

Exudate Consists of fluid and leukocytes that move from circulation to site of injury Nature and quantity depend on type and severity of injury and

Chemical mediators Histamine Stored in granules of basophils, mast cells, platelets Causes vasodilation and increased capillary permeability Serotonin Stored in platelets, mast cells, enterochromaffin cells

Cellular response Blood flow through capillaries in area of inflammation slows as fluid is lost and viscosity increases Neutrophils and monocytes move to inner surface

Inflammation Sequential response to cell injury that: Neutralizes and dilutes inflammatory agent Removes necrotic materials Establishes an environment suitable for healing and repair Inflammatory response

Health Promotion Prevention Teach about negative effects Provide support Early detection Initiate brief interventional techniques Refer for treatment Gerontologic Considerations Older adults are often unaware

Nursing Management Substance Use Nursing Assessment Screening, Brief Intervention, and Referral to Treatment (SBIRT) Screening for problems using standardized screening tools Brief intervention or teaching

Inhalants Household and workplace products contain chemicals with psychoactive properties when inhaled Rapidly absorbed and reach CNS quickly Most are depressants Long-term use can result