Pressure sore

Prevention

Ri 李孟如
2004/7/12
Definition

 Pressure sore = decubitus ulcers = bedsores

 Any lesion caused by unrelieved pressure resultin
g in damage of underlying tissue
 Localized areas of tissue necrosis that developed w
hen soft tissue is compressed between a bony prom
inence and an external surface for a prolonged perio
d of time
causes
 Pressure
 Interrupt circulation
 Shear
 Diminish circulation
 Friction
 Superficial and easily reversed
 Moisture
 Weaken the cell wall of individual skin cells
Norton scale
Modified Norton scale
Classification
 Stage I: Skin is intact, erythematous (reddened), and does not
blanch. Skin may be firm or boggy, warm or cool to the touch, pai
nful or itchy. Indicators in darker skin are a dark red, blue or purpl
e area; warmth; edema; induration, or hardness.
 Stage II: Superficial ulceration of the skin, appearing as an ab
rasion, a blister, or a crater. Partial thickness skin loss (dermis or
epidermis, or both).
 Stage III: A deep crater; full thickness loss of skin tissue, als
o involving subcutaneous tissue down to the fascia.
 Stage IV: Full thickness skin loss, with damage to bone, muscl
es, tendons, or joint capsules. May involve sinus tracts.
 Nonobservable: Covered with a dressing, an orthopedic device,
eschar, or slough. Cannot be visualized
I. Risk Assessment
 1. Consider all bed- or chair-bound persons, or those whose
ability to reposition is impaired, to be at risk for pressure ulcers.
 2. Select and use a method of risk assessment, such as the
Norton Scale or the Braden Scale, that ensures systematic
evaluation of individual risk factors.
 3. Assess all at-risk patients at the time of admission to health
care facilities and at regular intervals thereafter.
 4. Identify all individual risk factors (decreased mental status,
moisture, incontinence, nutritional deficits) to direct specific
preventive treatments. Modify care according to the individual
factors.
II. Skin Care and Early Treatment
 1. Inspect the skin at least daily, and document assessment
results.
 2. Individualize bathing frequency. Use a mild cleansing age
nt. Avoid hot water and excessive friction.
 3. Assess and treat incontinence. When incontinence canno
t be controlled, cleanse skin at time of soiling, use a topical
moisture barrier, and select underpads or briefs that are abs
orbent and provide a quick drying surface to the skin.
 4. Use moisturizers for dry skin. Minimize environmental fac
tors leading to dry skin such as low humidity and cold air.
 5. Avoid massage over bony prominences.
 6. Use proper positioning, transferring, and turning techniques
to minimize skin injury due to friction and shear forces.
 7. Use dry lubricants (cornstarch) or protective coverings to
reduce friction injury.
 8. Identify and correct factors compromising protein/ calorie
intake and consider nutritional supplementation/support for
nutritionally compromised persons.
 9. Institute a rehabilitation program to maintain or improve
mobility/activity status.
 10. Monitor and document interventions and outcomes.
III. Mechanical Loading and
Support Surfaces
 1. Reposition bed-bound persons at least every 2 hours, chair-
bound persons every hour.
 2. Use a written repositioning schedule.
 3. Place at-risk persons on a pressure-reducing mattress/chair
cushion. Do not use donut-type devices.
 4. Consider postural alignment, distribution of weight, balance
and stability, and pressure relief when positioning persons in
chairs or wheelchairs.
 5. Teach chair-bound persons, who are able, to shift weight
every 15 minutes.
 6. Use lifting devices (e.g., trapeze or bed linen) to move rather
than drag persons during transfers and position changes.
 7. Use pillows or foam wedges to keep boney prominenc
es such as knees and ankles from direct contact with ea
ch other.
 8. Use devices that totally relieve pressure on the heels
(e.g., place pillows under the calf to raise the heels off th
e bed).
 9. Avoid positioning directly on the trochanter when using
the side-lying position (use the 30° lateral inclined positio
n).
 10. Elevate the head of the bed as little (maximum 30° a
ngle) and for as short a time as possible.
rule of 30
 the head of the bed is
elevated to 30 degrees
or less
 the body is placed in a
30-degree laterally
inclined position, when
repositioned to either
side 
IV. Education
 1. Implement educational programs for the prevention of
pressure ulcers that are structured, organized, comprehensive,
and directed at all levels of health care providers, patients,
family, and caregivers.
 2. Include information on:
 a. etiology of and risk factors for pressure ulcers,
 b. risk assessment tools and their application,
 c. skin assessment,
 d. selection/use of support surfaces,
 e. development/implementation of individualized programs of
skin care,
 f. demonstration of positioning to decrease risk of tissue
breakdown, and
 g. accurate documentation of pertinent data.
 3. Include built-in mechanisms to evaluate program effectiveness
in preventing pressure ulcers.
AACN Clinical Issues, 14(4), p411-428, 2003
JAMA, Jan 8, 2003, 289(2)
PUSH scale
JAMA, Jan 8, 2003, 289(2)
AACN Clinical Issues, 14(4), p411-428, 2003
Database
 Agency for Healthcare Research and Quali
ty (AHRQ)
 Guidelines for Pressure Ulcer Prevention and Pre
ssure Ulcer Treatment
 National Pressure Ulcer Advisory Panel (N
PUAP)
Functional Analysis of cushions fo
r pressure-sore prevention
 IBV (Instituto de Biomecanica de Valencia) S
pain

 IMSERSO
 CEAPAT
 Hospital Nacional de Paraplejicos de Toledo,
CAMF-Guadalajara
Development (material, methods
and methodology used)
 Creation of a work group
 Study of bibliography, standards and
documentation
 Selection of cushion for pressure-sore
prevention
 Tests definition
 Selection of users
 Testing
 Evaluation Method
 Thank you
for your attention!