the wound bed of a patients pressure ulcer is red. what does this finding indicate to the nurse?

Pressure Injuries (Bedsores)

A pressure level injury (bedsore) is an injury that happens when dissimilar kinds of force are practical to the surface of the pare. In that location are several stages of pressure injuries that describe the severity of the injury. It is important to avoid infection when you have a pressure level injury. If the wound becomes infected, the rest of the body is at adventure.

Overview

Pressure Injuries

What is a pressure injury?

A pressure injury (too called a bedsore, pressure ulcer, pressure level sore, or decubitus ulcer) is an expanse of injured peel. A pressure injury happens when strength is applied on the surface of the skin. This force tin be a constant pressure on an area of skin or a dragging (shearing) force between the skin and another surface. These injuries usually happen over bony parts of the torso (hips, heels, tailbone, elbows, head and ankles). A pressure injury can become life-threatening if it advances to a deep wound or becomes infected.

What are the stages of a pressure injury?

There are 4 stages that draw the severity of the wound. These stages include:

Stage 1: This stage is discolored peel. The pare appears red in those with lighter skin tones and blueish/purple in those with darker peel tones. The peel does non flinch (turn white) when pressed with a finger.
Stage 2: This stage involves superficial damage of the skin. The top layer of skin is lost. It may too look like a cicatrice. At this stage, the top layer of skin can repair itself.
Stage 3: This stage is a deeper wound. The wound is open up, extending to the fatty layer of the skin, though muscles and os are not showing.
Stage 4: This stage is the most severe. The wound extends down to the bone. The muscles and bone are prone to infection, which can be life-threatening.

Who is at hazard for developing pressure injuries?

People with a limited amount of mobility or a total disability to move. Those in wheelchairs or bedridden are at particular risk and need to be moved or turned regularly.
Those with prosthetic (artificial) limbs. If the device does not fit properly, the pare can be irritated and a pressure injury tin can develop.
People with a loss of sensation. They are at risk because they may not feel the pressure being applied to the peel. As a result, they may non motion, which could worsen the damage.
Those with malnutrition. Wound healing is slowed when nutritional needs are not met.
The elderly. As people age, the skin naturally becomes thinner and more than easily damaged.

Symptoms and Causes

What are the causes of pressure injuries?

Pressure injuries are acquired when a force is practical to the skin, causing damage to the tissue. Several types of forcefulness include:

Pressure level: Abiding pressure level on the peel results from remaining in the same position for a prolonged flow of time.
Shear: Shear damage or a dragging force can occur when the head of the bed is raised and the body slides down. The skin sticks to the sheets, but internal structures are damaged.
Moisture: Fluids (sweat, urine, fecal affair) that remains on the skin can crusade the skin to go overly moisture, which increases the take chances for pressure injury development.

What are the symptoms of force per unit area injuries?

The symptoms of force per unit area injuries tin include:

Changes in skin color (not-blanchable redness in lighter skin tones and non-blanchable bluish/regal skin in darker skin tones)
Pare swelling, pain or tenderness
Peel that feels libation or warmer to the touch than other areas
Peel loss, exposing deeper layers of skin
Pus-like drainage from an open area of skin

Diagnosis and Tests

How are pressure injuries diagnosed?

Pressure injuries are diagnosed by your healthcare provider during a concrete examination.

Management and Treatment

How are pressure level injuries treated?

Pressure injuries can exist treated in many ways depending on the phase. Once the stage and severity of the wound is determined, information technology must be cleaned, usually with a saline solution. Later on the wound is cleaned, it needs to be kept clean, moist, and covered with an advisable bandage. There are several different types of bandages your physician may use to dress the wound. These include:

Water-based gel (hydrogel) with a dry dressing
Foam dressing
Hydrocolloid dressing
Alginate dressing (fabricated from seaweed)

Sometimes debridement is needed. This is a process of ridding the wound of expressionless tissue. Debridement is an important part of the healing procedure. It changes the wound from a long-lasting (chronic) one to a short-term (acute) wound. There are several types of debridement. These methods include:

Ultrasound: Using sound waves to remove the expressionless tissue.
Irrigation: Using fluid (often pressurized) to wash away dead tissue.
Light amplification by stimulated emission of radiation: Using focused calorie-free beams to remove the dead tissue.
Biosurgery: Using maggots to eliminate bacteria from the wound.
Surgery: Using surgery to remove the expressionless tissue and close the wound.
Topical: Medical-class honey or enzyme ointments.

Prevention

How can pressure injuries exist prevented?

The evolution of force per unit area injuries can be prevented through careful ascertainment of the pare and frequent repositioning in those who tin can't turn themselves. Tips to prevent pressure injuries include:

Keeping the skin clean and clear of bodily fluids.
Moving and repositioning the trunk ofttimes to avoid constant pressure level on bony parts of the body.
Using foam wedges and pillows to assistance relieve pressure on bony parts of the body when turned in bed.
Maintaining a healthy diet to avoid malnutrition and to assist in wound healing.

Outlook / Prognosis

What are the long-term consequences of a pressure injury?

If the wound becomes infected, the infection tin spread to other parts of the body. Several conditions that may occur if an infection spreads include:

Cellulitis: An infection of the skin.
Osteomyelitis: An infection of the bone.
Bacteremia: An infection of the blood.
Meningitis: An infection of the brain and spinal cord.
Endocarditis: An infection of the middle.

Living With

When should I phone call the doctor?

If you lot suspect you have a pressure injury, speak with your doctor. A pressure injury is easier to heal if it is discovered in the early on stages. It is important to prevent a wound from condign infected. Healing is delayed in an infected wound and the infection could cause bug in other areas of the trunk.

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Source: https://my.clevelandclinic.org/health/diseases/17823-pressure-injuries-bedsores