NURSES ROLE IN CARE &

PREVENTION OF
PRESSURE ULCER
 SPECIFIC OBJECTIVES
After the end of the ward education the staff will
be able to :
1. Enlist the purposes
2. Understand the definition and policy
3. Identify the stages of pressure ulcer
4. Enlist the procedures
 PURPOSES
• To describe the correct procedure to asses
skin integrity, prevention and care of
pressure ulcer.
• To prevent prolong pressure on potential
areas of pressure ulcer.
• To promote circulation to the skin.
• To promote healing of pressure ulcer.
• To promote safety and comfort.
• To identify patient on hi risk for developing
pressure ulcer.
• To identify pressure ulcer in early stages.
 DEFINITION
Pressures ulcers, decubitus ulcers or bedsores -
result when capillary blood flow to the skin or
underlying tissue is embedded.

These ulcers primarily result from unequal

distribution of pressure over bony prominences.
They most result from prolonged periods of bed
rest.
 •Stages of pressure ulcer:

STAGE 1 STAGE 2 STAGE 3 STAGE 4

1.Full thickness
1.Superficial or
skin loss with
partial thickness 1.Full thickness skin
subcutaneous
skin loss loss with extensive
damage
  destruction.
1 .redness in  
2.Ulcer involves  
the skin 2.Ulcer extends
epidermis or 2. Tissue necrosis
down to
dermis  
underlying fascia
 Skin abrasion 3. Damage to muscle.
3.Presents as deep
 blister
crater
• The Nursing Department provides a
system of reporting, surveillance
and follow up of incident of
pressure ulcer.
Pressure care is compulsory for all high-risk patients and admitted
patient with home acquired pressure ulcer. Risk factors include the
following:

• Sensory Impairment
• Acute illness
• Reduce Level of Consciousness
• Extremes of age (up to 65, less than 5 years of age)
• Previous history of pressure damage
• Vascular disease
• Severe chronic or terminal illness
• Malnutrition and Dehydration
 POLICY
• It is a nursing priority to perform comprehensive
assessment and identification of patients at risk for
bedsores or evidence of actual bedsores.

• Reassessment should be done if low risk and above,

and if there is a change in patient’s condition.

• Braden Risk Assessment form is use to identify

patients at risk for Pressure Ulcer.
 POLICY
• Any newly hospital acquired bedsore shall be reported by Healthcare
Event Reporting Form.

• Pressure Ulcer Notification form must be filled up and submitted to

Infection Control Department and Nursing Quality Department for the
following instances:

1. Patients who acquire bed sore from home:

If the pressure ulcer becomes worst, or the stage/grade

increases. An OVR must be submitted also to the Nursing Quality
Department.
2. Patients who acquire bedsore in the hospital.
 POLICY
• Patient safety and comfort is ensured when
changing patient’s position.

• Patient Health Education such as proper skin

care, proper nutrition and proper positioning/
turning is given to patient as well as family
members to encourage participation in patient
plan of care in prevention of Pressure Ulcer.
 PROCEDURE
• Assess the skin of patients at risk on
admission using Initial Assessment
form. Focus on bony prominences.
 PROCEDURE
• Assess patient for Braden Risk daily using Braden Risk Teaching
tool. Once patient is identified with risk; the following measures
should be applied:

Cleanse the skin routinely and whenever any soiling occurs, use
mild cleansing agent, minimal friction and avoid hot water.

Use skin moisturizers for dry skin.

Avoid massage over bony prominences.

Protect the skin from moisture associated with episodes of

incontinence or exposure to wound drainage.
 PROCEDURE
• Assess patient for Braden Risk daily using Braden Risk Teaching
tool. Once patient is identified with risk; the following measures
should be applied(CONT….):

Minimize skin injury from friction and shearing forces by using

proper positioning, turning and transferring techniques. Use
lubricants, dressing or padding to diminish the effects of friction
on the skin.
Administer nutritional supplements or more aggressive
nutritional intervention as needed.
Continue efforts to improve mobility and activity, such as sitting
on chair, assist in walking in the room, or change position every 2
hours or more frequent for bed ridden patient.
 PROCEDURE
• Clean the pressure ulcer daily by using careful, gentle motions
to minimize trauma. Do not use povidone-iodine-based agents
or hydrogen peroxide because they damage granulation tissue.
Use normal saline solution to irrigate and clean the ulcer.
Cleaning and dressing of existing bedsores shall be done daily
or as needed.

• Minimized direct pressure on the sore. Reposition the client at

least every 2 hours. Make a schedule for the position changes.

• Reduce shearing force by not elevating the head of the bed

higher than 30’ if the clients’ condition permits.
 PROCEDURE
• If the client cannot keep his/her weight off the
pressure sore, use a gel flotation mattress or air
mattress or other mechanical devices.

• When dressing a pressure ulcer, keep the ulcer

tissue moist and the surrounding skin dry.

• Always adhere to standard precautions and use

good hand hygiene to prevent infection.
 PROCEDURE
• Teach the client to move, if only slightly, to relieve
pressure.

• Encourage ambulation or sitting in a wheelchair if the

clients’ condition permits. Ambulation stimulates
circulation moving out of the bed can enhance feelings
of self-esteem and provide diversion.

• Provide ROM exercise as the clients’ condition permits.

ROM exercise helps maintain joint mobility and
stimulate circulation.
 PROCEDURE
• Document Nursing Plan of Care.

• Report any incidence of newly admitted bedsore to

the hospital immediately to the Nursing Supervisor
on duty.

• Monthly Statistical Indicators report shall be

submitted to the Nursing Quality Department.
 FORMS
• Braden Risk Reassessment Form

• Patient's Turning Record

• Pressure Ulcer Healing Chart

• Pressure Ulcer Notification Form

• Initial Nursing Assessment form

 REFERENCES

• AGH POLICY & PROCEDURE , PREVENTION OF

PRESSURE ULCER ,IPP – NR – GN – 06 – 008,
VERSION 2