PRESSURE

SORES (Bed
Sores)

Presented by:
Ms.CELINE ANTONY
 What are Pressure Ulcers?
An area of localised damage to the
skin and underlying tissue caused
by pressure, shear, friction and/or
a combination of these
European Pressure Ulcer Advisory
Panel EPUAP (2003)
Area of skin breaks down when no
movement occurs
Commonly referred to as bed sores,
pressure damage, pressure injuries and
decubitus ulcers........
 Pressure Ulcer Risk Factors
• Internal/patient-related
factors:
• Systemic disease: metabolic,
neurological, vascular, terminal illness
• Reduced mobility or immobility
• Sensory impairment
• Psychological e.g. depression
• Anaemia
• Malnutrition
• Level of consciousness
• Extremes of age
• Previous history of pressure damage or
poor skin condition
• Acute or chronic oedema
• Dehydration/fluid status- sweat,
incontinence
External factors:
Pressure - support surfaces, change
of position
Shear - positioning, mobility
Friction - moving and handling
techniques, patient education,
splinting, casts, positioning
Other factors
- Moisture - incontinence, sweating,
pyrexia, wound exudates
- Medication
Age: Older patients may have poor circulation-
less O2 to the tissue

Lack of Mobility: Pressure

ulcers form when a patient is left in one
position
in bed for too long.
Poor Appetite: Pts who are dehydrated
or have a poor appetite are at risk for
pressure ulcers.
Unwanted Moisture: Patients that are
incontinent of urine or stool or those
who sweat are at risk for a pressure
ulcer
Pressure Ulcers in the Past
Patients who have had a pressure
ulcer in the past are at greater
RISK of getting another one.
 Who’s at Risk?
Bedridden/wheelchair bound
Fragile skin/Older age
Chronic disease that prevents blood
flow
Spinal Cord Injury/Brain Injury
Alzheimer’s Disease
Pressure points on
the human body:
Supine position (lying on
back)
Prone position (lying on
stomach)
Lateral postion (lying on side)
Sitting position
Pressure Ulcer Staging
Stage I
Dark Skin

Epidermis;
nonblanching erythema
 Stage II

Partial thickness skin loss involving epidermis, dermis,

or both. The ulcer is superficial and presents clinically
as an abrasion, blister, or shallow crater.
 Stage III

Full thickness skin loss involving damage to,

or necrosis of, subcutaneous tissue/fascia
Full thickness skin loss with extensive destruction, tissue
necrosis, or damage to fascia + bone, tendon, muscle, cartilage.
• The National Pressure Ulcer Advisory Panel
has redefined the definition of a pressure ulcer
and the stages of pressure ulcers
• Suspected DTI
• Stage I
• Stage II
• Stage III
• Stage IV
• Unstageable
Suspected deep tissue injury
Purple or maroon localized area of
discolored intact skin or blood-filled
blister due to damage of underlying soft
from pressure and/or shear.
Unstageable
• Full thickness tissue loss in which the
base of the ulcer is covered by slough
(yellow, tan, gray, green or brown)
and/or eschar (tan, brown or black) in
the ulcer bed. from pressure and/or
shear*.
Effective management of
a pressure ulcer
The Braden Scale
 Braden Scale Norton Scale
Activity  
Mobility  
Incontinence 
Sensory Perception 
Moisture 
Friction & Shear 
Nutrition 
Physical Condition 
Mental Condition 
 Methods Used To Prevent
Pressure Ulcers
Identify areas where pressure ulcers most
frequently occur.
Keep skin clean and dry
Reposition residents at least every two
hours
Keep linen dry and free of wrinkles and
objects that cause pressure to the skin
Clean urine and feces from skin as soon as
possible
Make sure clothing and
shoes do not bind or
constrict
Pat skin dry when
bathing; never scrub
Encourage adequate
nutrition and fluids
Massage pressure
points when the
resident is
repositioned
Report any changes
in skin condition
immediately
 Bed cradle elbow protectors

Pillows Flotation pads

Preventive
Devices

Water beds pressure mattress

 Treatment
Relieve pressure in area (pillows,
cushions)
Physician can treat depending on stage
Avoid further trauma
Prevent infection by properly cleaning
open ulcers
Medication to promote skin healing
Calcium alginates or other fiber gelling
dressings: Absorbs drainage and turns to a gel
to maintain a moist wound bed

Impregnated gauze: Used for packing, can

deliver antimicrobial, medications and
moisture, for partial or full-thickness wounds.
Hydrocolloid: Contains gel-forming agents
Antimicrobials: Controls or decreases
bioburden (e.g., silver dressings,
hydrofera blue, cadezomer iodine,
honey)
Debridement is the removal of necrotic
tissue or contaminated foreign matter.
 DO NOT…
Massage the area
Damage tissue under the skin

 
                                       

Use donut-shaped or ring-shaped

cushions
Interfere with blood flow
Documentation of assessment, plan of
action and re-assessment is your
only proof of good care.

If it is not written
down ,
it never happened!
European Pressure Ulcer Advisory
Panel
Thank you for your time
& attention!