PRESSURE ULCER

PREVENTION & MANAGEMENT

SUMI NATH
Bsc. NURSING, MBA (HA), CCEPC
 DEFINITION & GOAL
Definition:
An area of localised damage to the skin and underlying tissue caused
by pressure, shear, friction or both combined. Commonly referred as
bedsore, pressure damage, pressure injury or decubitus ulcer.
Goal:
• Pre disposing factors are classified as intrinsic
• Prevention includes risk identification
• Implementing specific preventive measures
• Appropriate wound assessment according to the stages.
• Appropriate treatment, includes the management of local and
6
distal infections.
STAGE - 1

Skin is not broken but is red or discolored or may show

changes in hardness or temperature compared to
surrounding areas. When you press on it, it stays red and
does not lighten or turn white (blanch). The redness or
change in color does not fade within 30 minutes after
pressure is removed.
Normal skin layers
STAGE 2

The topmost layer of skin (epidermis) is broken, creating a shallow open

sore. The second layer of skin (dermis) may also be broken. Drainage
(pus) or fluid leakage may or may not be present.

Pressure ulcer over

the left ischial
tuberosity is shallow
with loss of dermis.
 The STAGE 3
wound extends through the dermis (second layer
of skin) into the fatty subcutaneous (below the skin)
tissue. Bone, tendon and muscle are not visible. Look
for signs of infection( redness around the edge of the
sore, pus, odor, fever, or greenish drainage from the
sore) and possible necrosis.

The right sacral

ulcer extends
into
subcutaneous
tissue.
No muscle,
bone, or tendon
is visible.
 STAGE 4
The wound extends into the muscle and can extend as far down as the bone.
Usually lots of dead tissue and drainage are present. There is a high possibility
of infection.
 RISK FACTORS

• Old age > 70

• Pre disposing medical conditions
• External factors that damages skin.Friction,shear, pressure
• Impaired mobility
• Smoking ( as an ongoing practice)
• State of confusion or disoriented
• Urinary or faecal incontinence
• Malnutrition
• Restrain to bed for various reasons
• Skin related disease conditions
• Immuno suppressive and chemotherapeutic agents
• Alcohol and drug abuse
PRESSURE ULCER LOCATIONS
BRADEN RISK ASSESSMENT
SCALE
 PREVENTION AND MANAGEMENT

• Carry out 3 times systematic skin inspection

• Reduce the factors that promotes dryness of skin

• Avoid massaging over the skin prominence

• Reduce the cause which creates moisture (in continence, perspiration, drainage)

• Promote minimum frictions and shear

• High risk score, 3 hourly position change mandatory

• Keep head of bed at the lowest elevation

 PREVENTION AND
• MANAGEMENT…….
Pay special attention to heal.

• Take appropriate nutritional assessment and appropriate action.

• Identify the issues which cause the ulcer and prevent.

• Pain level identification and management is mandatory.

• Psychological assessment and management need to include.

• Associated medical condition to be treated.

MATERIALS AND DEVICE USED IN HEALING PROCESS:

• Foam in the form of cushions

• Static air, water and combination of both

• Mattress with the alternating air, low air loss or air fluidised

• Mechanism which help in surface compress to <1"

Use of documentation towards healing:

• Surface area: Measure in centimeter with the ruler

• Exudate: Estimate portion of ulcer bed covered by drainage
• Appearance: evaluate the ulcer for tissue type (epithelial, granulation,
slough, necrotic)
• Score: Obtain total score,which indicates healing or deterioration
 Pressure Ulcer
CHECKLIST:
S# Items Expected marks Scored marks

1 Explain the normal layers of the skin. 10

2 Able to explain stage 1 and 2. 10

3 Able to explain stage 3 and 4. 10

4 Able to enumerate the different risk factors. 10

5 Identify the common areas prone to pressure ulcer. 10

6 Able to explain the score in Braden Risk Assessment Scale. 10

7 Nurse responsibility in the preventive aspect. 10

8 Nurse responsibility in the management aspect. 10

9 Knowledge on the material and devices used. 10

10 Knowledge on the method of documentation. 10

100

Evaluated by:

Evaluated by:
THANK YOU