Pressure Sore 08

Pressure Ulcer Ella Yu (VL)

Pressure Ulcer Decubitus ulcers, pressure sores or bedsores  Caused by unrelieved pressure Etiology  Due to localized ischemia  Deficiency in the blood supply to the tissue  Reactive hyperemia (bright red flush)  Vasodilation- compensate for the preceding period of impeded blood flow Two factors:  Friction  Shearing force 

Pressure Ulcers Risk factors:  Immobilty  Inadequate nutriition: hypoprotenemia, oedema  Fecal and urinary incontinence: maceration and excoriation  Decreased mental status  Diminshed sensation  Excessive body heat  Advanced age  Chronic medical condition  Other factors

Stages of pressure ulcer formation Stage 1: nonbalnchable erythema Stage 2: Partial thickness loss Stage 3: Full-thickness skin loss Stage 4: full-thickness skin loss with tissue necrosis or damage to muscle, bone or supporting structures

Figure 34.1

Four stages of pressure ulcers. (1 of 4)

Figure 34.1

Four stages of pressure ulcers. (2 of 4)

Figure 34.1

Four stages of pressure ulcers. (3 of 4)

Figure 34.1

Four stages of pressure ulcers. (4 of 4)

Figure 34.2

Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.

Nursing Intervention  Maintain

skin integrity  Prevention of pressure sore  Treating pressure sore 

Use appropriate dressing materials

Prevention of Pressure Ulcers  Routine

Systematic Skin Assessment

Inspect the skin head-to-toe in adequate light at least once a day  Teach patients and family members to inspect susceptible parts visually and by touch 

Assessment of skin integrity  

Assessment of the body pressure areas Norton’s Pressure Area Risk Assessment Form Scale 

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Scores of 15or 16 as indicators of risk

Braden scale     

A total of 23 points 15-18 points is considered at risk 13-14 points- moderate risk 10-12 points- high risk 9 or less- very high risk

Assessment of skin integrity Documentation  Location of the lesion  Size of lesion  Presence of undermining or sinus tract  Stage of ulcer  Colour of the wound bed and location of the necrosis or eschar  Condition of the wound margins  Integrity of surrounding skin  Clinical signs of infection

Prevention of Pressure Ulcers  Routine

Systematic Skin Assessment

Inspect the skin head-to-toe in adequate light at least once a day  Teach patients and family members to inspect susceptible parts visually and by touch 

Prevention of Pressure Ulcers  Reduce 

Exposure to Pressure

Frequent Patient Turning  Relieve

pressure on sensitive areas by turning at least every __ hours. Some patients may need to be turned more frequently  Use a written turn schedule  Encourage chair-fast patient to shift position every ______ minutes

Turning Schedule

2-hrly turning 300 tilt at lateral position Use positioning devices

(Potter & Perry, 1997)

Prevention of Pressure Ulcers  Reduce 

Exposure to Pressure

Appropriate Patient Positioning  Use

positioning devices to keep bony prominences from direct contact with each other  Keep heels off the bed with a positioning device  Avoid 90 degree lateral lying position  Utilize ___ degree oblique side lying position  Maintain patient in proper alignment both in bed and chair  Avoid positioning patient on pressure ulcer

Prevention of Pressure Ulcers  Reduce

Exposure to Pressure

 Pressure  Apply 

protective padding at bony prominences

_____________, ________________

 Use 

Reducing Surfaces

pressure reducing mattress

foam, alternating pressure mattress, gel or water bed, air-fluidized bed

 Use

pressure relieving cushions for chair- or wheelchair-bound patients  Pad casts and cast edges  Pad oxygen tubing around the ears

Mechanical devices for reducing pressure on body parts           

Gel flotation pads Sheepskins Pillow and wegdes Heel protectors Egg crate mattress Foam mattress Alternating pressure mattress Water bed Air- fluidized bed (static high –air-loss bed) Static low-air-loss bed Active LAL bed

Sheepskins heel protector

Pressure relieving devices

Ankle off the bed

Heels off the bed

Egg crate mattress

Alternating pressure mattress: uses a pump to increase or decrease the pressure

Low-air-loss bed: air-filled cushions into 4 or 5 sections- different level of firmless. reduce pressure at bony promenences site but increase other body area support

Air-fluidized bed (astatic high-air-loss bed): Forced temperature- controlled air is circulated around millions of tiny Silicon –coated beads, producing a fluidlike movement and provide uniform support to body contour

Prevention of Pressure Ulcers  Improve

Mobility and Activity Levels

 ___________________________  ___________________________  Avoid

over sedation and inactivity  Avoid restraints

Prevention of Pressure Ulcers  Reduce

Excessive Moisture

 _____________________________  _____________________________  _____________________________

_____________________________  ______________________________  ______________________________  Change wound dressing when needed  Pouch heavily draining wounds 

Prevention of Pressure Ulcers  Minimize

Skin Dryness

 ___________________________  ___________________________  ___________________________  ___________________________  ___________________________

Prevention of Pressure Ulcers  Prevent  Avoid

Friction and Shear

elevating the head of the bed more than 30 degrees unless medically inappropriate  Utilize a trapeze, bed linen and other positioning devices to avoid sliding and dragging patients across bed and chair surfaces while repositioning  Protect heels and elbows  Use soft, clean and wrinkle-free sheets  Apply protective film dressings  Pat dry, do not rub with towel

Prevention of Pressure Ulcers  Improve A

Nutrition

well-balanced diet with sufficient protein and calorie content  Vitamin supplements containing vitamin C, vitamin A, and zinc  Improve suboptimal food intake  Improve fluid intake

Prevention of Pressure Ulcers  Education  Health

care professionals  Caregivers  Patients

Treating of pressure ulcer 

Focus of pressure ulcer treatment: 

local care of the wound  Wound dressing  Choice of appropriate wound dressing material 



Transparent adhesive films, hydrogels, hydrocolloids, alginates

supportive measures, e.g. adequate nutrition, relief of pressure

Treatment of pressure ulcer

(Kozier, Erb, Berman, & Burke, 2000)

Pressure sore is preventable Florence Nightingale (1861) ….

Saw pressure sore as the fault of the nurses rather than the disease.

Pressure sore is preventable Nursing accountability •Inadequate assessment •Inappropriate prevention and management •Inappropriate choice of dressing •Improper documentation

Reference 

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Kozier, B., Erb, G., Berman, A. J., & Burke, K. (2000). Fundamentals of nursing: Concepts, process, and practice. (6th ed.). New Jersey: Prentice Hall Health. Kozier, B., Erb, G., Berman, A., & Snyder, S. (2004). Fundamentals of nursing: Concepts, process, and practice. (7th ed.). New Jersey: Prentice Hall. Potter, P. A., & Perry, A. G. (1997). Fundamentals of nursing: Concepts, process, and practice. (4th ed.). St. Louis: Mosby. Taylor, C., Lillis, C., & LeMone, P. (2001). Fundamentals of nursing: The art & science of nursing care. (4th ed.). Philadelphia: Lippincott.

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