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Completely niet Unresponsve (does not moan, fine, or grep) to painful stimu because of diminished level of consciousness Lite ability to fee! pain aver most of body Constanty moist: Skin opt moist almost constantly oy perspiration, urine, etc Dampness dotected ‘very time patient is moved o turned Bedfast: Confined to bed Completely immotit: Does rot make evan slight changes in body or extreity position ‘without assistanes Very poor: Never ats a complete meal Rerely eats more than ‘one thi of any food offered Eats two servings or loss of protein (meat or dary products) per day Takes figs poorly; does not take aula itary supplement ls NPO and/or ‘maintained on cleat liquide or V infusions for more than 5 days 2. Very limited: Responds ‘ony to paint tinal ‘iscomtort except by moaning or rectleseness Has @ sensory impairment that mits the abily tg feel pain lor dlscomfcR over hat of body Very moist: Skin ofton but not always moist Linen must Be changed atleast once a shit Chair fast: Abit 10 walk several ited or onexistent Cannot tear own weight and/or must be assisted into char oF wheelchair Very limited: Makes ‘occasional slight changes in body or fextremity postion but unabie to make frequent or significant changes independent 2, Probably inadequate: Faroly eats @ complete ‘meal and generally eats ‘only about half of any food offered Protein intake Includes only three servings of meat or day products er day Oceasionaly takes a cletary supplement Receives less than ‘optimal amount of liquid dit o tube feeding 3 Slightly mites Fesponds to verbal ‘commands but cannot always communicato ‘iscomfart of ned to be tumed Has some sensory impairment, which Fits ability to feel pain fr discomfort in one or ‘wo extremitise ccasionaty moss: ‘Skin occasionally moist, roquting oxtra linen change approximately once day Waiks occasionally Walks occasionally during day but for very short distances wih oF without ascitance Spends moat of each shift in bed or chair Siighty limited: Makes frequent though slgnt changes in body oF extremity postion Independentiy Adequate: Eats over half of most meals Eats a total of four servings of protein (reat, day products) tach day Cccasionaly refuses a meal but usualy takes a supplement when otfored Is on a tube-feeding or "TPN regimen that probably meets most of nutritional needs 4 {No impairment FResponds to a commands Hae no sensory ‘that Would i to feo or von ciscomtor FRaraly moist: Stn Usually oy linen requires changing at routine intervals Waits frequent Walks outsice rom least twice a cay a Inside room at last once every 2 hours ‘uring valdng hous No tinitations: Maas ‘major and fequent changes in postion without assistance Excelent: Eats most of every meal Never refuses a meal Usually eats a toa of four or more servings of meat and dary products Sceasionaly eats betwoon meals Doee not require supplementationrondasied Azosuas sie uonepag ‘spuapuadapu Uuonsod auey> 10 ura 20U s30p pu dpe Ajpeniau 201 4 STE (1102 “1839 Ae1o)) uoys sox90eU aAMVsOU MASSON ‘unaoeg sure u09 wep 3 ‘sneag) Suyeay pasejap 40 pouredus us yosos s.auionoyop IsaHnIMN | 3yFIOM o2 spea ORIN aaenbopEN, yo Aypedng Suphamea-uosikxo soonpas fpaa} wigoplourmyy poseasnaq] 2srou urs Sco} stsu0qdeyp suyiuEddwO: somssn Jo spuewap 2qoqerou sosear>u 8 rou so0p pue ainssaud woyy uoswossip 33 02 a|gcun st wuDHIE > oanssoad ‘saoqor o8 Spuspusdapur wonsodss 40 wan) 02 ajgqeun st auaREg 92189 AVNAN PH AYA) BH aUoHEd 23ey RL eA SAOHDe) IS Syauap! pur 2109 aanuasasd amsiunupe of poo sauneiaag ER arht soaopt wai uworysn ateyp aofpa somneur uonngmsypaLamnssa4] C) posal uonusIIN>o¢] Joon uous EY esatpsoute pure uorepos Aff oouunaucout Asem 10 8 (sygedoanou smaqjaur soroqerp toy soaeyp sonoma wp aujnosea poy 1 puoo yours a) ssopuosy ‘von UE usu sana rs) oydruoy “'9) so) sta pou 20 sR ‘aojabunioy 199jn aunssaud 20) a SguoRed nor 0 |e ee sui e041 mojeg Ht WoUUdOENAQ quowdinbs — | seam ammsaig 0} 1S J >] uO sap}aap aansise Woy uo ie Sue vodoyy vunys sauoned ayp ur 3ea1q 40 ssoupas Sue auod>yL tunop s9pis Arpuoiseoco 1ng un ea 10 804 pq 0 23849 Uf Uotysod p08 Aeneas SUELIEN, sys. 20 pq uonsod ‘So@p Ja4O 20 poof sureuNeR —‘siuEases “HBYD “e=YE nou sue0e quape@ wos fuunp Marac00 ©} sepye Ageqord ‘dn ys 01 wibvons. Ups axous 8 Suing psn weSWNS ‘courts ‘54 pu AquopuedopUt your sounbos sreyo pur pea Ur sano 20 fiqe0) SOnoW ‘weygaud ured ON “e swayed yenueiod 2 fg sane unre) soccer ono) weisueo owe 01 spe9| voneyoe ‘yonseds eoumpse eupeu! ww Buonsodas ‘eyo J0 pq Lunop sep Auuentis gssodu cyoous Yeu BUEN anosnim Bunt e109 Duvow u eauejeCe uunwprew-o-oe0pous seunbou :wagodd “1 co UL a ie ea a ee eaeDehydration xisting pressure ulcers m History of pressure ulees 2 Select an agency-approved risk assessment tool such as the Braden Scale of Norton Scale. Perform risk assessment when patient enters health care setting ani repeat on regularly scheduled basis icant chany condition (WOCN, (Obtain risk score (see Tables 18-1, 18-2, and 18.3) and evaluate its meaning based on patients unique characterist Assess condition Fig. 18-1), a Inspect for skin discoloration (redness in. light-tone skin purplish or bluish in darkly pigme feel) an 1s of pressure (see red skin) and tisue consistency (fim or boxt or palpate for abnormal sensations (Nix, 2012) b Palpate discolored area, release your fingertip, and look for blanching. © Inspect for pallor and mote Inspect for absence of superficial skin layer. © Inspect for localized heat, edema, or induration, especially in individuals with darkly pigmented skin (EPUAP and NPUAR, 2008). Assess patient for alditional areas of potential presure injury fa Nares: Nasogastrie (NG) tube, oxygen cannula b Ton Ears: oxygen cannula, pillow Drainage or other tubing ve and lips: oral away, endotracheal (ET) tube @ Wound drainage f Indwelling urethral (Foley) catheter 9 Orthopedic and positioning devices Pennies Jeonates and very young children are at high risk, with the being most common site of pressure ulcer occurrence (Wl 2010}, There is loss of mal thickness in older adules, impairing to distribute pressure (Pieper, 2012). Results in decreased skin elasticity and turgor. int of presse, fiction, andi Eclemarous tissues ae less tole Limit surfaces available for position changes, placing aval tissues at increased risk Tensile strength of skin from previously healed pressure ul 80% or less; therefore thi as undam: hy a area cannot tolerate pressure ai nd Sparks-Deftiese, 2012) alid and reliable risle assessment tools evaluate. patient for developing a pressure ulcer. Identifying risk factor contribute 8 tial for skin breakdown allows breakdown. Risk cutoff score depends on instrument used. The score int Wri factors thae contributed to it and minin those specific deficits, Body weight against bony prominences places underlying i risk for breakdown, Indicates that tissue was under pressure; hyperemia is am easing risk foe physiologic response to hypoxemia in tissues. fon palpation an area of redness blanche (lightens in cla indicates normal reactive hyperemia; the tissue is nt ail skin breakdown, Tissue that does not blanch when pi indicates abnormal reactive hyperemia; an indication of pal ischemic injury. Persistent hypoxia in tissues that were under pressure: an ab physiole Represencsearly pres ‘wound that may have resulted from feiction andlor shat and induration have been identi ns for pressure uleer development. Since ti son darkly pigrnens ic response re ulcer formation, usually pariel-¢hil Localized heat, edem: always possible to see signs of redn these alditional signs should be considered in as (EPUAP and NPUAP, 204 Patients at high risk have multiple sites for pressure necros death) in addition to bony prominences ‘Stress against tissue at exit ste or if tubing is caught under anil of the body Wound dean: caustic to skin and underlying tissues. For female patients the catheter can put pressure on the bi especially when edematous. For male patients presse catheter not properly anchored can put pressure on thet the penis and urethea Improperly fitted or applied devices have the potential dif presure on adjacent skin and underlying tissue Clinical Decision Point Inspect skin around and beneath orthopec devices (e.g, cervical collar, braces, er east). 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Use ard (See Chapter 9) to transfer patient from to stretcher Immobility and inactivity reduce pat % ability of independently change ps ty to feel the sensation of fi of pre «reposition Reduces direct contact of the trochanter with the supp ect contact between bony pi sunt of pressure exerted on ti Reduces the amount of pressure on the saer Friction and shear damage underlying skin, Proper repositioning of patient prevents di provides slippery surface to educe friction(o10z SO ,n\) SouaunuoAd duo s9A0 amnssandsoangunsypar sa] a4 joer aeiaites Rane ees egigg Tals eon G sagiys s9prsuory "Noy> w ur Huns sp yuan © a]Hy% 1990 pasu sofunyo won sod yey, s8ay3oue9 Ayes pu neon pulinoyy ‘apps 20 pure Sumaey “eyunoue‘aouunuoDKy ‘souapUadop pod # eypyaan SIH) sta BuLNOT|OS kp JO SUE aA Aaxp fF IUDLE dlojaxsp193qn aunssud Jo) used 2s09 aui04 131KOU A901 ‘suey Uuoqsod yim djoy spas quoted j1 auerqsse apisoid ot ‘Sosnepas pur SOgytIoK se ys soomosar AayumumMD AAUP] « 129 ewion “pppoat gy) Fanpeay sass urpeo| ‘pogmunmp st woneiauatas jeuuspide 30) atu a2 pur ‘soousutwosd Auog 1940 won2101d Fupped $89] 01 “onsen snoaueanagns s89j s} 2s9qU] "Urp yye pur sig] pa, ca xds9 5 30} UnAg "ap se 30H sy sap ay NOPE AOPIO UL» se yas astuey auON joann 216o}oqu010p i. 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Treatment of Pressure Ulcers BI Video Clip Treatment of patients with pressure ulcers requires a holistic approach using a thorough assessment of patients and their ability heal. Have a good understanding of the identiied goal for a atient’s overall care before implementing topical pressure uleer treatment. The principles of managing patients with pressure uleers includes systematics skin environment conducive to healing, One wort of patients, reduction or elimination of he cause ikdown, and management that provides an pressure ulcer, take steps to control or eliminate it. For example, the ulcer is related to ungelieves! pressure, choose the appropriate choose the ap healing tional status, an priate chair pad. Next asvess the patients wound: ities: cardiovascular and pulmonary function, nutri conditions that interfere with wound heali such as diabetes, steroid administration, and immunosuppression 2). Wound assessment tools ment Tool (BWAT) (Ni stn determining the individual (Doughty and Sparks-Deffiese he Bates-Jensen Wound Ass and the PUSH tool can a as for differ The principle that guides the selec ment g pressure ulcers, on and use of topical dres (Rolstad, Bryant, and Nix, 2012). The best environment for woun healing is moist and free of necrotic tissue and infection, Choose interventions and dressings designed to support a clean, moist wound bed. Perform a thorough assessment of the wound and the Periwound skin before initiating wound therapy, Data obtained will help to plan the appropriate care fora patient with a pressure ulce No specific studies demonstrate the benefit of using one cleanse wer another for pressure ulcers. In most eases water or saline is aning a clean wound (WOCN, 2010). Hy. vas once widely used but is now known to cause tissu tissue, or heavy drainage, use a cleanser that is noneytotoxic to wound, and the type of devitalized tissue to meet the characteristics of the and Nix, 2012). The choice of a n the type o wound dre wound tissue in the hase of the wound, the amount of w lana, the presence or absence ation of the wound, the sizeof the wo ASSESSMENT 1 Assess patient’ level of comfort on a pain scale of Ovo 10. I patient is in pain, determine ifa pm pain medication has been eal andl administer 2 Determine if patient has allergies to topical agents he onder for topical agent(s) andor dressings. wound dressings include transparent films, hydra els foams, calcium alginates, gauze, and antimierl (See Chapter 39). The type of dressings to use will pressure ulcer characteristics change; frequent woul is key Advanced wound care therapies used in s rowth factors, ele ed skin. Ga wound fluid and scimulate both » applied topically. Pulsed tion isa procedure usually performed by physical the goal pressure wound therapy, and tissue ‘oceur natural epithelialization wh f inereased wound heal ses in unts of pr elven f specialized methods, Negative therapy (NPWT) applies suction to facilitate healing wound fluid (Netsch, 2012). NPWT works via 1 Sil gue) pla usive dresing. Ti negative pressure to a wound through suction i und fluid (Netsch, 2012} kin develops living cells that youl bed to facilitare wound closure, Ady and a wound filler (dressing such as foam wound and covered with a semion applies ealing and collect w Tissue-engineer clean woun: therapies may play an important role in presute ult haf use only after consultation with a wound care expert Delegation and Collaboration The skill of treatment of pressure cannot be delegated t nurse instructs the NAP to: ulcers and dresingdl nursing assseive personnel (NA Report any wound drainage thar mighe be cn linen skin, indicating the need to change the de alternative dressing + Repor any new areas of redness, blistering, Equipment G Protective equipment: clean gloves, goggles, cover loves (optic hag for dre O Measuring device U Sterile cotton-tipped applicators (chy sterile applicators) s ordered) dered) Cleansing agent (as Dressing of choice based on patient wound! character a a 2 Sterile solution a Hypoallergenic tape (if needed) 3 Documentation records Dressing change should not be a traumatic © wound pain before, during, and (Hopf etal, 2012). ahate Topical agents could contain elements that cause lca nsres din ation of pesunyeoy puiom pue wounean 2996 yp Ho. spunon uazaynp ateuuneto> sasiuesuo aa29yC] sean sansa Jat ssa nok se popsou say prey pare togy ‘uisyuvSu001910 Jo UOISSTUSMEN SON 29 Suyssup panos paou Swoys UNAS punow.ad Uo WoIRI2d0y anpssaitond sone2ypu 129) we jo apa tp 28 wonApAIOD US powredyy aotouo axp 221 ‘eurep ans jo douanbay pue ada aweoypar Seu ayepnxo Jo adda pur wunowy ae wo) FUIACW St uno w ZIP soWOIPUL ans oHHNU pure wonesiojoo 40 wonsaju ajo aguasoad ay aaeaypey Ao Sn eos 40 onset 9K SuBpIGap saxon aNssA PEI yo aiusasad ny v yBtas puna “Sursseyp yo aatay a4p pUuE uyay punos. jo ssazond axp do UoneMLofsl jerpuD sapirord ppunom sup ul anssn yo aka ypea Jo aftemoouad azeuuxoudde 241 sso] ans Jo 3umnowe saunNIMap Ypdap puneg, sage jo Raugaaapaan ps (z10z ‘*1N) auawamseaw auanisuco auf uunseayy “awn 3930 3 pur 1sa8u0] ay) axon Sasso (6002 UWNAN PUP ayjj ajqeasasun sv payuawnop ase spuno, ‘won Dn joyp Punow ap 4 soase ISPs Buyeayy se sary 2518 29217) )VAAdA) 21414 20U 81 280g pruniows Jo {adap uo paseq) 420] aunssaid © Suysosse Jo dem e sy BURG (0102 ‘NOOAN) pu aie punom jo saupanzoy soun9q, 90 wad rbunean sup sap oye payeurueyuoa jo Suypuey zxdoud soxowoxd Zuiso4p pyo yo yesodep sadoag “aluey Sussaap 409 wage ajgissaaoe ue s9p{A04g spiny Kpox, 02 aunsodxa yeruapiare u9491d Spiaoig pur susjurasooror Jo worssrusuen ssompayy “owstd us 22 PY Yn MoH ID of muon poyucpy ays wou eee Yow 9. npio ay ff tuoind 0 4 sowoon Pana ps3] spe prnow Huanseayy ‘wor cad 30 ‘oystoudso twojsgiod ood suyjeayy punoss Sun29y $103224 19) pury wiojied pur ‘prerdosdde preanp Aoqon9 pur ‘uoqeapenjoypido Aupi2la3 uoneMopul sig) (7-81 x83 ojos urys suaped uo pase maKuSsesse APO PRE spans “ses © jo aoueand 24) pu Sou uunomuad Jo won 10{00 pave Ho open 20) wnys a4 sure sus ‘sonsu2oeieyp “wunoue ayp aquosaq] mp fo ZRH (pay putnom 4p wy ans fenraoiad pu alk ayp aqua jpg pumom Jo wong [punos axp Suruiexa oa 29S0y pasog B ‘papanu 3) ‘pare pap amnseaut ox soneyidde podium ins 8352) :spuU 40 ‘stop Sms “FuguRuLpun fo 22K 9 das (vonensnyt 295) dap 29% 0} rowaypdde padd-uonn # a7) “yppt pa 49} 20) 2p shutunseaus ajqusodsip v 250) Joomo1d 40u: oie punoas auf 0 Ypdap pue “yppus * p ad puna 71 2 pol (1-81 x0 25) puna fo ain @ a Pung, 1 punoss axp auaqyn ays pog ayp aquaseq to sous Supsaup 294 sd usu banponoad Bap 2p 3 seus sty, s19p4 Mojo Aus 2 panos 300809 2nuniuo2 pu sea}2uzeued punoasSuysn spunom auaried sm odsip #5534 2) Sa aed wn sono way le pe oop oat 53 snised wortsed pu yesoua Supssoup oye 00 3 auotity puey uopng -sureun> aprspoq a uo 0 supp ip 1p f UULE2C] YUOed UO|SI00G IR9 Assess patiene’s nutritional status (see Chapter 30). Clinically Delayed wound healing occurs in poorly nourished pl significant malnutrition is present if (1) serum albumin level is less than 3.5, illustration) (WOCN, 2010), Cs. <~e .. <__tttat sg or woa + EEE eee es No Assossment of physical and psychosocial bamers | 4 to intake a oe S| supplements and assistance | Sasi at. Yes-No Decisions {5 Interventions STEP 9 Nutritional asessment parenteral nutrition. From Bergstrom N ct a celle, Md, 1994, | Department of Health and Human Serices. Clinical Decision Point When you pce matron, conser « mnonal cnsdaionw mis pon’ de 0 promote wand ant; TPN, total AHICPR Pub No. Puliie Health Seruce 10 Assess patient's and caregiver’ understanding of prevention, Patient and caregiver need to partner with health cate prov ‘treatment, and factors conteibating to recurrence of pressute to prevent further skin breakdown, uloers (WOCNco: i 5S MOA any SPINA Ang “NoNoU raf urs IEA ex PENODaWPLY » 25>) Og UO su ann ays sof qo 2seq punos fuor01d aqry Fnyeory punom arene} ov arumuosAND ato SEELEY isp pIopPOOIN TST area snap ase omy 2 paroatgns Uys pur axepNx? ou Jo [PUNE Ml sonomod UPys 19euT AYO Pur USUTUOA}AUS AsIOU e SUTE sey sioo]n jeroyredns i990 Afddhy ‘Sunsaap wy sum priowsow aun, Pa ronbopy susp fo Cucquosgn 3p 20s WY UOd WO ano kap tou sop puna wn soye “AuD4p uno fo wm” oy sof x (6¢ 12x04 298) panos 8 3 won} 99H sua ve 20 ‘sntoyqnne eojdon 40 sous9 Sassy ag jest pue panos & 03 aimsfous sioayyap sane uIssoup s9409 Aap w SSUIsSOUP SHOU v (6c uO (c102 iN pe Suekag (peasy) Aap rye % “ Sup panos ao iwaulUONAUD asjou UIEINIEW pjnoys FaIsaq_ —2o|M aanssas UO paseq Huyssup aweudoKde ue aE jpunouns fudaoy PUP UDMDRCUEMT PUNO JO s9fdiou FONT OHS. COLL. EE spb y suty Susu} pumam 3930 op“ » Bupagey nh 2 un Ravn quod UOISGE (0102 ‘NO0aK) 2269 Jeudo jo sysam p on 7 say ponou st Rulpeay ot jt asn 105 parapysu0D I og pInoys pure punoss jo vopsngoIg aseaNDop sono RUE yeardoy sonorqniee ores Axpesy on parydde (wonesypdde jo Aouanbay 2 saopaoup rou ase souudzu oe pHns 199)N Wea|D01 aNESN peap apLgap souuKzuG —_UMIeyRUEUE ayFDade wO}jo4) suds uIpugop aku ido) page 2 ap 01 sv apconatoucn Kuo 97) uyOe WORSBBG sauueo> won ysue9|o-punom so4po 20 2k Shuyssup asou pue uae yeoydon furdjdae au0jaq a0gpINS I9O|M UERIE) —apRIS UE aU sayddns pur auacadynbs An vuoreanp Sjuaey pu auaned uiaunean 9 pue J99]7 aqp NOG 19 Sapumnodde ve s9yo pan sion dsouoasn Aue 391300 Yaanxueasaypastioneudso Suoweseday, i a “eno sojn Anse ayy unopyeany sotpany a0j steve suyeWaN wuDHIRy —JOKpAY} anop4ss ple IeAU SITENIAE NPFS |PIAAD 5AAARG eq) npyaypay 2aoue9 Aju pu marae o> funow odds oy wood azenbape sopracid Adesayp [ou nN sofia unum pr yaoje> staan aU POO RLAN sesteap punon uuetuo9 02 axetxtoxdde st Sutssaup Sopias st ikeurp [oUOREPpE ON, Aen pe Aupyeoy su Suyeayy paemon Buon s prom sey 2989p L43 ose plot 3: e24 seison ssoaioad pus ssaooad AuoneuUNeyU u} ase—s99p. 809p) 1 sboyp Suypuncuns ag oad sj onsth uoRHE) a soveanop afeinesp 2910 mnpasoud jo won afluiod Huyoyo souomno pa ‘ONIN spi ao vepypuna suse wo posoy preppmpnp a0 a sau pox] UPA $89] :oR MU pou (Cuouyp ‘ounse) ute + (ausoiu1 uns paredusy + sejd ausune9n 29) aS nyu anes annoayauy + foyyqown poorseyd posted + uypuesian apap ou aK RE SONOVIG ONIS Perr) daisGen -Available in a sheet or in tube Maintains moist environment to facilitate wound healing 5) Caleium alginate Highly absorbent of wound exudate in heavily draining wi Foam dressings Protectiveand prevents wound dehydration also absorbs to-large amounts of deainag Silver impregnated dressin Controls bacterial burden in wound ). Wound fillers Fills shallow wounds, hydrates, and absorbs tain hypoallergenic tape or adhesive dressing shee Used to secure nonadherent dressing. Prevents skin inital Eee a Pressure Presbure Uler eer Stage Status Dressing Comments Expected change Adjuvants Intact None ‘Alows visual assessment. Resolves slowly without Tuning schadl Transparent Protects from shear. Do ‘epidermal oss over 7 Support hy orossing ot use in presence of ‘Nutrtional spe excessive moisture. Pressured Hydrocolloid Does not alow visual ‘bed or use fe ‘Composite fn Limits shear Hydrocaloid ‘Change wien seal of o 7 Manage Inontia dressing breaks, maximal woar time 7 days. Hydrogel Provides moist anvronment, Hydrecoloid ‘Change wien seal of Hols through Seo previous sa Hydrogel covered dressing breaks, maximum granulation and Evaluate presi vith foam dressing wear time 7 days. Apply _reepthelaization redistribution Cover wound to protect and acorb moisture Calcium alginate Use when thece is significant nidata. Cover with secondary dressing, Use with normal saline or ‘thor prescribe solution, Wring out excess solution; Unfold to make contact with wouncs Growth factors Use with gauze per manufacturer intructione. Hiyarogel covered ‘See stage il clean Heals through ‘Surgical consi With foam dressing ‘granulation, scar ‘may be necessay, tissue development, for closure. See land reepthelazation. stagas I and iL Calcium alginate Use with significant exudate; must cover with secondary dressing Gauze ‘See stage il clean Unstageable Wound covered Adherent fim Faciltaes sorting of char Its at edges as Sco provious agee with eschar ‘chiar. healing progresses ‘Surgical consutati may be considered for debridement. Gauze plus ordered Delivers solution and wicks ‘May be considered et solution wound drainage. slow debridement Enzymes Breaks down eschar, providing debridement None Rarely, feschar Is dry and intact, no dressing i u allowing eschar to act as Physiologic cover