Assignment On Prevention Of Decubitus Ulcer

Definition: Decubitus ulcer also known as pressure sores or bed sores. Decubitus are ulcerated tissue
subjected to pressure from lying on mattress or sitting on a chair for a prolonged period of time resulting
in the slowing of circulation and finally death of the tissue.

Common sites:

1. Supine Position
 Back of the head(occiput)
 Scapula
 Sacral region
 Elbow
 Heels
2.Side lying Position

 Ears
 Acromion process of shoulder
 Ribs
 Hip
 Knee
3.Prone position
 Ears
 Cheek
 Breast (in female)
 Genitalia(in males)
 Knees and toes
Causes of Pressure Sores:

1.Pressure:
 The pressure over these areas are increased in the following condition-
a) When there is lumps and creases on the bed
b) Incorrect positioning of the body
c) Infrequent change of position

2.Friction:

 Friction of the skin with a rough or hard surface can cause tissue damage
 Friction is also caused due to the rough Sponge clothes and prolonged massage without
lubricant
3.Moisture:
 The skin contact with moisture for a period of the time can lead maceration of the skin
 4.Presence of pathogenic organism:
 Lack of cleanliness source of pathogenic organism and infection settles on the skin .

Clients Susceptible Pressure Sores:

 Elderly bedridden patient, who make very little movement in bed

 Obese client
 Very thin client, having very little subcutaneous tissue to the bony prominence
 Patient who have spinal cord injury

Risk factor:

 Diabetes
 Heaet disease
 Kidney disease
 Immobility
 Poor nutrition
 Spinal cord injury

Prevention Of Pressure Ulcer:

Purpose: to prevent complications

Policy:

 To ensure pressure ulcer prevention measure are carried out so as to prevent the
development of HAPU
 Adequate number of staff to reposition bedridden patient regularly
 Shift supervision to ensure that bedridden patient are repositioned at proper intervals.

Equipment:

 Body lotion
 Dressing as required
 Pressure reducing device

Stages of Pressure Ulcer:

 Stage 1: pressure ulcer . Intact skin with non blanching redness

 Stage 2: pressure ulcer. Shallow open ulcer with red pink wound/ blister
 Stage 3: pressure ulcer full thickness tissue loss with visible
subcutaneous fat
 Stage 4: pressure ulcer full thickness tissue loss with exposed muscle and
bone

Procedure:

 Assess the skin condition and identify stages of ulcer development

  Inspect skin 2 hourly
 Massage area gently to increase circulation using lotion moisturizer
 Turn & position of bedridden patient 2 hourly and document it
 Maintain skin hygiene
 Maintain asepsis while dressing
 Daily examination of Decubitus prone client for redness, discoloration, or blister
on the pressure points
 Provide adequate diet high in protein and vitamin
 Use special mattress or beds to decrease the pressure on body parts
 Cut nails to avoid scratching on skin
 Teach the client and their relative regarding hygienic care of skin

6 Steps Of Back Care To Prevent Pressure Ulcer:

 EFFLURAGE
 PETRISSAGE
 TAPPOTMENT
 KNEDDING
 HACKING
 CUPPING
*Each steps is 5 times

Management Of HAPU:

Stage 1: Relieve pressure off the affected area

Stage 2: a)For friction prone area apply thin dressing / transparent dressing

b) For non friction prone area Clean the area with betadine & leave it open to dry

Stage 3: Wound environment regulator dressing must be used

Stage 4:. a) wound environment regulator dressing must be used

 b) May consider using vac dressing large quantity of secretions

*BRADEN SCALE IS USED AS ASSESSMENT TOOL FOR PRESSURE

ULCER