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    Pressure Ulcer Care

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    Rosalyn Yu
    Pressure ulcers, also known as bedsores or decubitus ulcers, are injuries to the skin and underlying tissue that result from prolonged pressure on areas of the body. They are most common over bony areas like the heels, ankles, hips, and tailbone. Pressure ulcer care involves prevention, wound cleaning and dressing, managing pain and infection, and promoting healing. Pressure ulcers are classified into stages based on their depth and severity, from non-broken skin (Stage I) to exposure of muscle, bone or tendons (Stage IV). Nursing interventions include repositioning, managing moisture and exudate, debridement of dead tissue, and dressing selection based on the stage and characteristics of the ulcer.

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    Pressure Ulcer Care

    Uploaded by

    Rosalyn Yu
    143 views39 pages
    Pressure ulcers, also known as bedsores or decubitus ulcers, are injuries to the skin and underlying tissue that result from prolonged pressure on areas of the body. They are most common over bony areas like the heels, ankles, hips, and tailbone. Pressure ulcer care involves prevention, wound cleaning and dressing, managing pain and infection, and promoting healing. Pressure ulcers are classified into stages based on their depth and severity, from non-broken skin (Stage I) to exposure of muscle, bone or tendons (Stage IV). Nursing interventions include repositioning, managing moisture and exudate, debridement of dead tissue, and dressing selection based on the stage and characteristics of the ulcer.

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    Pressure ulcers, also known as bedsores or decubitus ulcers, are injuries to the skin and underlying tissue that result from prolonged pressure on areas of the body. They are most common over bony areas like the heels, ankles, hips, and tailbone. Pressure ulcer care involves prevention, wound cleaning and dressing, managing pain and infection, and promoting healing. Pressure ulcers are classified into stages based on their depth and severity, from non-broken skin (Stage I) to exposure of muscle, bone or tendons (Stage IV). Nursing interventions include repositioning, managing moisture and exudate, debridement of dead tissue, and dressing selection based on the stage and characteristics of the ulcer.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    143 views39 pages

    Pressure Ulcer Care

    Uploaded by

    Rosalyn Yu
    Pressure ulcers, also known as bedsores or decubitus ulcers, are injuries to the skin and underlying tissue that result from prolonged pressure on areas of the body. They are most common over bony areas like the heels, ankles, hips, and tailbone. Pressure ulcer care involves prevention, wound cleaning and dressing, managing pain and infection, and promoting healing. Pressure ulcers are classified into stages based on their depth and severity, from non-broken skin (Stage I) to exposure of muscle, bone or tendons (Stage IV). Nursing interventions include repositioning, managing moisture and exudate, debridement of dead tissue, and dressing selection based on the stage and characteristics of the ulcer.

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    Pressure Ulcer

    Care

    Pressure - the continuous physical


    force exerted on or against an object
    by something in contact with it.

    Pressure ulcer- also called bed sores or


    decubitus ulcer
    Are injuries to skin and underlying tissue
    resulting from prolonged pressure on the
    skin. Bedsores most often develop on skin
    that covers bony areas of the body, such as
    the heels, ankles, hips and tailbone.

    Pressure ulcer care- a nursing intervention defined


    as facilitation of healing in pressure ulcers .

    Induration- The hardening of a normally soft


    tissue or organ, especially the skin, due to
    inflammation, infiltration of a neoplasm, or
    accumulation of blood.

    Erythema- redness of the skin caused by


    congestion of the capillaries in the lower
    layers of the skin. It occurs with any skin
    injury, infection, or inflammation.

    Maceration- the softening and breaking


    down of skin resulting from prolonged
    exposure to moisture.

    Debridement- the removal of damaged


    tissue or foreign objects from a wound.

    Exudate- A protein-rich fluid, such as serum


    or pus, that has leaked from blood vessels
    or been discharged by cells or tissues.

    Importance of pressure ulcer


    care
    to prevent infection
    Avoid further injury or friction
    To prevent complications
    To promote wound healing
    To determine the stage of the ulcer
    To promote comfort to the patient
    To protect the wound and surrounding tissue

    Factors that frequently act in


    conjunction with pressure to produce
    pressure ulcer

    Friction
    Force acting parallel to the skin surface
    Can abrade skin removing the superficial
    layers

    Shearing Force
    Fowlers position

    Body tends to slide downward toward the foot of the bed

    Transmitted to sacral bone & deep tissues

    Skin over the sacrum, superficial tissues tends not to move


    Deeper tissues are firmly attached to skeleton & move
    downward

    Shearing force in the area where deeper tissues & superficial


    meet

    Force damages the blood vessels & tissues in the area.

    RISK FACTORS of PRESSURE


    ULCER
    Immobility
    Inadequate Nutrition
    Fecal & Urinary Incontinence
    Decreased Mental Status
    Diminished Sensation
    Excessive Body Heat
    Advanced Age
    Chronic Medical Conditions
    Other factor

    Etiology in producing pressure ulcer


    Localized ischemia
    (Deficiency in the blood supply to tissue)
    (Tissue is caught between 2 hard surfaces-bed & bony skeleton-)

    Blood cannot reach the tissues

    Cells will be deprived of O2 & nutrients


    Waste products of metabolism accumulate in the cells

    Tissue dies

    Damages to small blood vessels (prolonged)

    Skin appears PALE

    Relieved, REACTIVE HYPEREMIA (Bright Red flush)


    Flush d/t VASODILATION (extra blood floods to the area to compensate impeding
    blood flow)

    (-) redness, no tissue damage


    (+) redness, tissue damage

    Classification of bed sores

    Stage I
    The beginning stage of a pressure sore has the
    following characteristics:
    The skin is not broken.
    The skin appears red on people with lighter skin
    color, and the skin doesn't briefly lighten (blanch)
    when touched.
    On people with darker skin, the skin may show
    discoloration, and it doesn't blanch when touched.
    The site may be tender, painful, firm, soft, warm
    or cool compared with the surrounding skin.

    Nursing Interventions
    GOAL: Protect the skin and remove the cause
    Change position in bed or chair every two hours.
    Assess need for support surface.
    Maintain head of bed at 30 degrees or less,
    unless contraindicated.
    Use draw sheet for repositioning.
    Do not massage reddened areas.
    Elevate heels off bed with pillow or protective
    boots/splints.
    Avoid positioning on affected area

    Stage II
    The outer layer of skin (epidermis) and part of the
    underlying layer of skin (dermis) is damaged or
    lost.
    The wound may be shallow and pinkish or red.
    The wound may look like a fluid-filled blister or a
    ruptured blister.

    Nursing Intervention
    Goal: Protect the skin and manage exudates; closure
    and regrowth of skin
    Manage exudates/moisture: Apply wound dressing;
    change every 35 days and when needed.
    None-to-light exudates: Ointment to affected area, a
    thin wound dressing
    Moderate-to-heavy exudates: Adhesive wound
    dressing or a non-adhesive wound dressing secured
    in place

    Stage III
    the ulcer is a deep wound:
    The loss of skin usually exposes some fat.
    The ulcer looks crater-like.
    The bottom of the wound may have some yellowish
    dead tissue.
    The damage may extend beyond the primary wound
    below layers of healthy skin.

    Nursing interventions
    Goal: Protect and keep wound clean; manage
    exudates; and reduce wound size
    Manage exudates/moisture: Apply a wound dressing to
    create a moist wound environment, which assists in
    autolytic debridement of wounds covered with necrotic
    tissues
    None-to-light exudates: Apply a thin wound dressing or
    gel
    Moderate-to-heavy exudates: Adhesive or nonadhesive wound dressing secured in place; selection of
    dressing influenced by size and location of the
    pressure ulcer; a rope or sheet wound dressing may be
    needed in specific situations or to pack the wound;

    Stage IV
    A stage IV ulcer shows large-scale loss of tissue:
    The wound may expose muscle, bone or tendons.
    The bottom of the wound likely contains dead
    tissue that's yellowish or dark and crusty.
    The damage often extends beyond the primary
    wound below layers of healthy skin.

    Nursing interventions
    Goal: Protect and keep wound clean; manage
    exudates; and reduce wound size
    Manage exudates/moisture: Apply a wound dressing to
    create a moist wound environment, which assists in
    autolytic debridement of wounds covered with necrotic
    tissues
    None-to-light exudates: Apply a thin wound dressing or
    gel
    Moderate-to-heavy exudates: Adhesive or nonadhesive wound dressing secured in place; selection
    of dressing influenced by size and location of the
    pressure ulcer; a rope or sheet wound dressing may
    be needed in specific situations or to pack the wound;

    Unstageable
    A pressure ulcer is considered unstageable
    if its surface is covered with yellow, brown,
    black or dead tissue. Its not possible to see
    how deep the wound is.

    Suspected Deep Tissue Injury


    A purple or maroon localized area of discolored intact
    skin or blood-filled blister due to damage of underlying
    soft tissue from pressure and/or shear.
    The area may be preceded by tissue that is painful,
    firm, mushy, boggy, warmer or cooler as compared to
    adjacent tissue.
    A deep tissue injury may be difficult to detect in
    individuals with dark skin tones. Evolution may include
    a thin blister over a dark wound bed. The wound may
    further evolve and become covered by thin eschar.
    Evolution may be rapid exposing additional layers of
    tissue even with optimal treatment.

    Surgical management
    Surgical debridement - involves cutting away dead tissue.
    Mechanical debridement - loosens and removes wound
    debris. This may be done with a pressurized irrigation device,
    low-frequency mist ultrasound or specialized dressings.
    Autolytic debridement - enhances the body's natural process
    of using enzymes to break down dead tissue. This method
    may be used on smaller, uninfected wounds and involves
    special dressings to keep the wound moist and clean.
    Enzymatic debridement - involves applying chemical
    enzymes and appropriate dressings to break down dead
    tissue.

    Pharmacological management

    Nonsteroidal anti-inflammatory drugs such as


    ibuprofen (Motrin IB, Advil, others) and naproxen
    (Aleve, others) may reduce pain.
    Antibiotics. -Infected pressure sores that aren't
    responding to other interventions may be treated
    with topical or oral antibiotics.
    Muscle relaxants such as diazepam (Valium),
    tizanidine (Zanaflex), dantrolene (Dantrium) and
    baclofen (Gablofen, Lioresal) may inhibit muscle
    spasms and help sores heal.

    Different types of dressings


    used for pressure ulcer

    Absorptive Dressings: These dressings are either


    applied directly to the wound or on top of other primary
    dressings. Absorptive dressings are intended to
    remove the drainage from the bed sore that may
    impede healing. Most absorptive dressings are
    changed on a daily basis. However, excessive
    drainage from a bed sore may require more frequent
    dressing changes.
    Common types of Absorptive dressings include:
    Medipore, Silon Dual Dress, Aquacel Hyrofiber
    Combiderm, Absorbtive Border, Multipad Soforb,
    Iodoflex, Tielle, Telefamax, Tendersorb, Mepore and
    Exu-dry.

    Alginates: Alginates are dressings made from fibers


    either completely or partially made from seaweed or
    algae. Alginates absorb drainage from a bed sore and
    form a gel-type barrier over the wound that ensures a
    moist environment to assist in healing wounds.
    Alginates are commonly used in treating deep bed
    sores as they allow wounds to heal even with dressings
    in the wound.
    Common types of Alginates include: Algicell, Algisite,
    Carrasorb, Curasorb, Dermacea, Dermaginate, fybron,
    Gentell, Kaltostat, Kalginate, Maxorb, Silvercell,
    Sorbsan, Seasorb, Tegagen

    Antimocrobials: In wound care, antimocribials refer


    to dressings that contain antibacterial products or
    antibacterial creams used to reduce or kill bacteria
    in bed sores. Before using antimocrobials, a
    physician must first determine if the bed sore is
    infected. A bed sore can be tested for infection by
    doing a culture. In some circumstances where a
    patient may be particularly at risk for developing an
    infection, a physician may prescribe antimocrobials
    as a preventative measure.
    Common types of Antimicrobials include:
    Tegaderm, Amerigel, Anasept, Silverton, Contreet,
    Aquacel, Silverderm, Algidex, Colactive, Kerlix,
    Tefla, Arglase, Maxorb, Optifoam, Acticoat,

    Hydrocolloids / Hydrogels: Hydrocolloid dressings have


    gel-like properties and absorb fluids from the wound.
    Because hydrocolloid dressings form a moisture-proof
    barrier they frequently used with incontinent patients as
    they can keep urine and feces out of the healing wounds.
    Hydrocolloids should be used in un-infected bed sores.
    A physician should determine the frequency with which a
    hydrogel dressing should be changed. Generally
    hydrogel dressings are changed from 2 to 7 times per
    week.
    Common types of Hydrocolloid / Hydrogel dressings
    include: Tegagel, Biolex, Carrasorb, Purilon, Repair
    Hydrogel, Dermasyn, Dermagran, Curasol, Restore, Nugel, Curafil, Skintegrity, Panoplex

    pressure ulcer care


    Guidelines
    Use inAseptic
    Technique

    procedure
    Wound cleansing should not be undertaken to
    remove 'normal' exudate
    Cleansing should be performed in a way that
    minimizes trauma to the wound
    Wounds are best cleansed with sterile isotonic
    saline or water
    The less we disturb a wound during dressing
    changes the lower the interference to healing

    Fluids should be warmed to 37C to support cellular


    activity
    Skin and wound cleansers should have a neutral
    pH and be non-toxic
    Avoid alkaline soap on intact skin as the skin pH is
    altered, resistance to bacteria decreases
    Avoid delipidizing agents as alcohol or acetone as
    tissue is degraded
    Antiseptics are not routinely recommended for
    cleansing and should only be used sparingly for
    infected wounds

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