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PRESSURE ULCER CARE

After 8 hours of classroom discussion and demonstration the Level IV nursing students
will be able to:
1. Define the following
1.1 pressure
1.2 pressure ulcer
1.3 pressure care
1.4 induration
1.5 erythema
1.6 maceration
1.7 debridement
1.8 exudates
2. explain the significance of ulcer care in relation to the nursing practice
3. distinguish different factors frequently act in conjunction with pressure to produce
pressure ulcer
4. recite some etiology in producing pressure ulcer
5. differentiate classification of bed sores
6. enumerate sign and symptoms of bed sores development
7. cite out the different techniques in preventing the development of bed sores
8. identify different treatments in bed sores
9. illustrate different types of dressings used for pressure ulcer
10. enumerate the guidelines in pressure ulcer care
11. state the different principles of infection control in patient with pressure ulcer
12. discuss the different nursing responsibilities before, during, and after pressure
ulcer care

1. Pressure - the continuous physical force exerted on or against an object by
something in contact with it.
2. Pressure ulcer- also called “bed sores” or “decubitus ulcer”

It occurs with any skin injury. or inflammation. especially the skin. Fowler’s position  Body tends to slide downward toward the foot of the bed . due to inflammation. such as the heels. or accumulation of blood. Exudate.- 3.a nursing intervention defined as facilitation of healing in pressure ulcers. that has leaked from blood vessels or been discharged by cells or tissues. 6.redness of the skin caused by congestion of the capillaries in the lower layers of the skin. infection. Are injuries to skin and underlying tissue resulting from prolonged pressure on the skin. Erythema. Importance of pressure ulcer care clean 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 frequently act in conjunction with pressure to produce pressure ulcer 1 Friction  Force acting parallel to the skin surface  Can abrade skin removing the superficial layers  more prone 2 Shearing Force  Combination of friction & pressure. hips and tailbone.the removal of damaged tissue or foreign objects from a wound. infiltration of a neoplasm. Bedsores most often develop on skin that covers bony areas of the body. 5. Induration. such as serum or pus. 4.A protein-rich fluid. 8.the softening and breaking down of skin resulting from prolonged exposure to moisture. Maceration. Pressure ulcer care. 7. ankles.The hardening of a normally soft tissue or organ. Debridement.

harbor microorganisms & prone to skin breakdown & infection  Moisture from incontinence  Skin Maceration (tissue softening from prolonged soaking)  epidermis more easily eroded & increased risk for injury  Digestive enzymes in feces  Skin Excoriation/Denuded Area (area of loss of superficial layers) Decreased Mental Status  Unconscious or Heavily Sedated because they are less able to recognize & respond to pain assoc. & Vit. Pain or any activity that can hinder person’s ability to move. . Extreme Weakness. C. etc. Stroke.  Hypoproteinemia  dependent edema  decreased elasticity. Inadequate Nutrition  Prolonged inadequate nutrition causes wt. with prolonged pressure Diminished Sensation  Paralysis. RISK FACTORS 1 2 3 4 5 Immobility  Reduction in control of movement person has. Transmitted to sacral bone & deep tissues  Skin over the sacrum.  Decreases Person’s ability to respond to injurious heat & cold & to tingling sensation that signals loss of circulation. vitality  Injury  Edema  increased distance between capillaries and cells  slowing O2 diffusion to cells & metabolites away from cells. loss. Fluids. &  Inadequate intake CHON. muscle atrophy. Fecal & Urinary Incontinence  Any accumulation of secretions or excretions in irritating to the skin. CHO. 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.  Resulting from Paralysis.

Advanced Age  Aging process brings about several changes in the skin making the older person prone to impaired skin integrity.  REACTIVE HYPEREMIA (Bright Red flush) .6 7 8 9 Excessive Body Heat  Severe infection + increased Body temp.  Affect the body’s ability to deal with effects of tissue compression. Chronic Medical Conditions  Diabetes and cardiovascular disease – compromise oxygen delivery to tissues poor perfusion delayed healing Other factor  Poor lifting and transferring techniques  Incorrect positioning  Hard support surfaces  Incorrect application of pressure-relieving devices 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.

painful. The wound may be shallow and pinkish or red.(Body’s mechanism for preventing pressure ulcers. The wound may look like a fluid-filled blister or a ruptured blister. The bottom of the wound may have some yellowish dead tissue. Stage II    The outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) is damaged or lost. The site may be tender. Stage IV   A stage IV ulcer shows large-scale loss of tissue: The wound may expose muscle. The ulcer looks crater-like. tissue damage Classification of bed sores Stage I The beginning stage of a pressure sore has the following characteristics:     The skin is not broken. firm. and it doesn't blanch when touched. bone or tendons. and the skin doesn't briefly lighten (blanch) when touched. The skin appears red on people with lighter skin color. the skin may show discoloration. The damage may extend beyond the primary wound below layers of healthy skin. soft. no tissue damage (+) redness.¾) Flush d/t VASODILATION (extra blood floods to the area to compensate impeding blood flow)  (-) redness. On people with darker skin. Stage III the ulcer is a deep wound:     The loss of skin usually exposes some fat. lasts ½ . . warm or cool compared with the surrounding skin.

pink or darkened area with your finger. brown. warmer or cooler as compared to adjacent tissue. Test your skin with the blanching test: Press on the red. mushy. The area may be preceded by tissue that is painful. 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. pink or darkened color within a few seconds. boggy. The area should go white. discolored or darkened area It may feel hard and warm to the touch. Different techniques in preventing the development of bed sores . Evolution may be rapid exposing additional layers of tissue even with optimal treatment. then blood flow has been impaired and damage has begun.  The bottom of the wound likely contains dead tissue that's yellowish or dark and crusty. 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. Unstageable A pressure ulcer is considered unstageable if its surface is covered with yellow. It’s not possible to see how deep the wound is. If the area stays white. firm. so it is important to look for other signs of damage like color changes or hardness compared to surrounding areas. remove the pressure and the area should return to red. black or dead tissue. The damage often extends beyond the primary wound below layers of healthy skin. A pressure sore has begun if you remove pressure from the reddened area for 10 to 30 minutes and the skin color does not return to normal after that time. Sign and Symptoms of Bed Sores Development First signs      reddened. The wound may further evolve and become covered by thin eschar. Dark skin may not have visible blanching even when healthy. indicating good blood flow.

unless contraindicated.  Do not massage reddened areas. change every 1–3 days and if needed. selection of dressing influenced by size and location of the pressure ulcer. cover different treatments in bed sores    Reposition patient every two hours Clean wound with water and mild soap and pat dry Apply dresssings Surgical procedures .  None-to-light exudates: Ointment to affected area. a rope or sheet wound dressing may be needed in specific situations or to pack the wound.  Assess need for support surface.  Manage exudates/moisture: Apply wound dressing.Stage 1 Treatment goals Protect the skin and remove the cause II Protect the skin and manage exudates.  Use draw sheet for repositioning.  Maintain head of bed at 30 degrees or less.  Elevate heels off bed with pillow or protective boots/splints. and reduce wound size intervention  Change position in bed or chair every two hours. 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. closure and regrowth of skin III and IV Protect and keep wound clean. change every 3–5 days and and when needed. manage exudates. a thin wound dressing  Moderate-to-heavy exudates: Adhesive wound dressing or a non-adhesive wound dressing secured in place  Manage exudates/moisture: Apply a wound dressing to create a moist wound environment.  Avoid positioning on affected area.

Curasorb. Silvercell. low-frequency mist ultrasound or specialized dressings. This method may be used on smaller. Tegagen . uninfected wounds and involves special dressings to keep the wound moist and clean. others) — may reduce pain. Lioresal) — may inhibit muscle spasms and help sores heal. Enzymatic debridement involves applying chemical enzymes and appropriate dressings to break down dead tissue. However. Alginates are commonly used in treating deep bed sores as they allow wounds to heal even with dressings in the wound. Kalginate.  Antibiotics. Dermaginate. Iodoflex. Gentell. Most absorptive dressings are changed on a daily basis. Common types of Absorptive dressings include: Medipore. Maxorb. Dermacea. This may be done with a pressurized irrigation device. tizanidine (Zanaflex). fybron. Telefamax. Infected pressure sores that aren't responding to other interventions may be treated with topical or oral antibiotics. Autolytic debridement enhances the body's natural process of using enzymes to break down dead tissue. Silon Dual Dress. Seasorb. 2 Alginates: Alginates are dressings made from fibers either completely or partially made from seaweed or algae. Absorbtive Border. 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. Advil. Tielle. Absorptive dressings are intended to remove the drainage from the bed sore that may impede healing. Multipad Soforb. Carrasorb. Kaltostat. Tendersorb. excessive drainage from a bed sore may require more frequent dressing changes. Algisite. Mepore and Exu-dry. Pharmacological management  Nonsteroidal anti-inflammatory drugs — such as ibuprofen (Motrin IB. Mechanical debridement loosens and removes wound debris. Sorbsan. Common types of Alginates include: Algicell.  Muscle relaxants — such as diazepam (Valium). dantrolene (Dantrium) and baclofen (Gablofen. Aquacel Hyrofiber Combiderm. others) and naproxen (Aleve.    Surgical debridement involves cutting away dead tissue. Different types of dressings used for pressure ulcer 1 Absorptive Dressings: These dressings are either applied directly to the wound or on top of other primary dressings.

Tefla. Contreet. Restore. Nugel. 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 Principles of infection control in patient with pressure ulcer  . A bed sore can be tested for infection by doing a culture. Silverton. Before using antimocrobials. antimocribials refer to dressings that contain antibacterial products or antibacterial creams used to reduce or kill bacteria in bed sores. Curafil. Amerigel. Maxorb. Kerlix. Aquacel. Common types of Antimicrobials include: Tegaderm. Panoplex Guidelines in pressure ulcer care           Use Aseptic 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 37°C 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. Carrasorb. Acticoat. Hydrocolloids should be used in un-infected bed sores. Colactive. Skintegrity. Optifoam. Repair Hydrogel. Arglase. Generally hydrogel dressings are changed from 2 to 7 times per week. Common types of Hydrocolloid / Hydrogel dressings include: Tegagel. Biolex. Algidex. a physician may prescribe antimocrobials as a preventative measure. Purilon.3 Antimocrobials: In wound care. a physician must first determine if the bed sore is infected. Dermagran. In some circumstances where a patient may be particularly at risk for developing an infection. 4 Hydrocolloids / Hydrogels: Hydrocolloid dressings have gel-like properties and absorb fluids from the wound. A physician should determine the frequency with which a hydrogel dressing should be changed. Anasept. Curasol. Because hydrocolloid dressings form a moistureproof barrier they frequently used with incontinent patients as they can keep urine and feces out of the healing wounds. Silverderm. Dermasyn.

during. and after pressure ulcer care .Nursing responsibilities before.