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PRESSURE ULCERS By By Mr. M. Mr. M. Shivanandha Shivanandha Reddy Reddy
Bed Sores DEFINITION: DEFINITION: • A A Pressure Ulcer Pressure Ulcer or Decubitus Decubitus Ulcer injury injury to the skin and other underlying to the skin and other underlying tissue, usually over a tissue, usually over a body prominence a result of a result of prolonged unrelieved pressure. prolonged unrelieved pressure. or Pressure Sore Pressure Sore or Ulcer or or Bedsore Bedsore is is localized or localized body prominence, as , as
Risk Factors 1. 1. Friction Friction 2. 2. Shear Shear 3. 3. Impaired Sensory Perception Impaired Sensory Perception 4. 4. Impaired Physical Mobility Impaired Physical Mobility 5. 5. Altered Level Of Consciousness Altered Level Of Consciousness 6. 6. Fecal And Urinary Incontinence Fecal And Urinary Incontinence
Risk Factors 7. 7. Malnutrition Malnutrition 8. 8. Dehydration Dehydration 9. 9. Excessive Body Heat Excessive Body Heat 10. 10.Advanced Age Advanced Age 11. 11.Chronic Medical Conditions Chronic Medical Conditions- -Diabetes, Cardiovascular Diseases. Cardiovascular Diseases. Diabetes,
Pathophysiology Various risk factors act on areas of soft tissue overlying bony prominence When this pressure exceeds normal capillary pressure Occlusion & tearing of small blood vessels Reduced tissue perfusion Ischemic necrosis Pressure sore
Stages / Classification Of Bedsores • Staging systems for pressure ulcers are Staging systems for pressure ulcers are based based on on the depth of tissue the depth of tissue destroyed. • Based on the depth there are four stages Based on the depth there are four stages of bedsores of bedsores 1. 1. Stage I Stage I 2. 2. Stage Stage II II 3. 3. Stage Stage III III 4. 4. Stage Stage IV IV destroyed.
Stage I: Nonblanchable Redness of Intact Skin • Intact skin Intact skin presents with presents with nonblanchable erythema erythema of a localized of a localized area usually a bony prominence. a bony prominence. • Discoloration Discoloration of the skin, of the skin, warmth, edema or or pain may also be pain may also be present present • Stage I indicates Stage I indicates “at “at- -risk” • Involves only the Involves only the epidermal layer epidermal layer of skin. nonblanchable area usually over over warmth, edema risk” persons. persons. of skin.
Stage II: Partial-thickness Skin Loss Or Blister. • A A partial thickness loss partial thickness loss of dermis presents as a shallow open ulcer with as a shallow open ulcer with a red wound bed without slough wound bed without slough • Stage II Stage II is damage to the is damage to the epidermis and the dermis the dermis. In this stage, the ulcer may be . In this stage, the ulcer may be referred to as a blister or abrasion. referred to as a blister or abrasion. of dermis presents a red- -pink pink epidermis and
Stage III: Full-thickness Skin Loss (Fat Visible). • A stage A stage III ulcer loss. Subcutaneous fat may be loss. Subcutaneous fat may be visible; but bone, tendon, or muscle is bone, tendon, or muscle is not • Epidermis, dermis and subcutaneous Epidermis, dermis and subcutaneous tissues tissues involved involved • subcutaneous layer has a relatively poor subcutaneous layer has a relatively poor blood supply. So its difficult to heal. blood supply. So its difficult to heal. III ulcer is a full is a full- -thickness tissue thickness tissue visible; but not exposed. exposed.
Stage IV: Full-thickness Tissue Loss • A stage IV ulcer A stage IV ulcer is is is is the deepest, the deepest, extending into the muscle, tendon or extending into the muscle, tendon or even bone. even bone. • Full thickness tissue loss with exposed Full thickness tissue loss with exposed bone, tendon or muscle. bone, tendon or muscle.
Complications • Cellulitis Cellulitis • Bone and joint infections Bone and joint infections • Sepsis Sepsis • Cancer Cancer
Prevention • Bedsores are easier to prevent than to Bedsores are easier to prevent than to treat. Although wounds can develop in treat. Although wounds can develop in spite of the most scrupulous care, it's spite of the most scrupulous care, it's possible to prevent them in many cases. possible to prevent them in many cases.
Prevention 1. 1. Position changes Position changes Changing position frequently and consistently is Changing position frequently and consistently is crucial to preventing bedsores. Experts advise crucial to preventing bedsores. Experts advise shifting position about every 15 minutes that shifting position about every 15 minutes that you're in a you're in a wheelchair wheelchair and at least once every two and at least once every two hours, even during the night, if you spend most of hours, even during the night, if you spend most of your time in bed. your time in bed. 2. 2. Skin inspection Skin inspection Daily skin inspections for pressure sores are an Daily skin inspections for pressure sores are an integral part of prevention integral part of prevention
Prevention 3. Nutrition 3. Nutrition A healthy diet is important in preventing skin A healthy diet is important in preventing skin breakdown and in aiding wound healing breakdown and in aiding wound healing Adequate hydration to maintain the skin Adequate hydration to maintain the skin integrity. integrity. 4. Lifestyle changes 4. Lifestyle changes – – Quitting smoking Quitting smoking Exercise Exercise - - Daily exercise improves circulation Daily exercise improves circulation 5. 5. Use pressure Use pressure- -relieving devices relieving devices such as air mattress, water mattress. mattress, water mattress. such as air
Treatment • 1. Changing positions often. 1. Changing positions often. Carefully follow the schedule for turning and repositioning the schedule for turning and repositioning — approximately every 15 minutes if in a approximately every 15 minutes if in a wheelchair and at least once every two hours wheelchair and at least once every two hours when in bed. If unable to change position on when in bed. If unable to change position on own, a family member or other caregiver must own, a family member or other caregiver must be able to help. be able to help. • 2. Using support surfaces 2. Using support surfaces. These are special cushions, pads, mattresses and beds that cushions, pads, mattresses and beds that relieve pressure on an existing sore and help relieve pressure on an existing sore and help protect vulnerable areas from further protect vulnerable areas from further breakdown. breakdown. Carefully follow — . These are special
Treatment • 3. Cleaning. 3. Cleaning. It's essential to keep wounds It's essential to keep wounds clean to prevent infection. A stage I clean to prevent infection. A stage I wound can be gently washed with water wound can be gently washed with water and mild soap, but open sores should be and mild soap, but open sores should be cleaned with a saltwater (saline) solution cleaned with a saltwater (saline) solution each time the dressing is changed. each time the dressing is changed. • 4. Controlling incontinence 4. Controlling incontinence
Treatment • 5. Removal of damaged tissue (debridement 5. Removal of damaged tissue (debridement). ). To heal properly, wounds need to be free of To heal properly, wounds need to be free of damaged, dead or infected tissue. damaged, dead or infected tissue. • 6. Dressings. 6. Dressings. • 7. Oral antibiotics. 7. Oral antibiotics. • 8. Healthy diet. 8. Healthy diet. • 9. Educating the caregiver 9. Educating the caregiver
Treatment • Surgical repair Surgical repair • Tissue flap. Tissue flap. • Plastic surgery may be required to replace the Plastic surgery may be required to replace the tissue. tissue. • Other treatment options Other treatment options Researchers are searching for more effective Researchers are searching for more effective bedsore treatments. Under investigation are bedsore treatments. Under investigation are hyperbaric oxygen hyperbaric oxygen and the topical use of and the topical use of human growth factors. human growth factors.
Role Of Nurse In Prevention & Management Of Bed Sores • The nurse should be continuingly assessing the The nurse should be continuingly assessing the client who are at risk for pressure ulcer client who are at risk for pressure ulcer development development Assess the client for: Assess the client for: The predisposing factors for bed sore The predisposing factors for bed sore Development. Development. Skin condition at least twice a day. Skin condition at least twice a day. Inspect each pressure sites. Inspect each pressure sites. Palpate the skin for increased warmth. Palpate the skin for increased warmth.
ROLE OF NURSE….. Inspect for dry skin, moist skin, breaks in skin Inspect for dry skin, moist skin, breaks in skin Evaluate level of mobility. Evaluate level of mobility. Evaluate circulatory status ( Evaluate circulatory status (eg pulses, edema). pulses, edema). Assess neurovascular status. Assess neurovascular status. Determine presence of incontinence Determine presence of incontinence eg. Peripheral . Peripheral Evaluate nutritional and hydration status. Evaluate nutritional and hydration status. Note present health problems. Note present health problems.
ROLE OF NURSE….. Interventions for a patient with Decreased sensory Interventions for a patient with Decreased sensory perception perception • Assess pressure points for signs of bed sore Assess pressure points for signs of bed sore development. development. • Provide pressure Provide pressure- -redistribution surface. redistribution surface. Interventions for a patient with incontinence Interventions for a patient with incontinence • Assess need for incontinence management. Assess need for incontinence management. • Following each incontinent episode, clean area Following each incontinent episode, clean area and dry thoroughly. and dry thoroughly. • Protect skin with moisture Protect skin with moisture- -barrier ointment. barrier ointment.
ROLE OF NURSE….. Interventions to avoid Friction and shear Interventions to avoid Friction and shear • Reposition patient using draw sheet and lifting Reposition patient using draw sheet and lifting off surface. off surface. • Use proper positioning technique. Use proper positioning technique. • Avoid dragging the patient in bed Avoid dragging the patient in bed • Use comfort devices appropriately. Use comfort devices appropriately.
ROLE OF NURSE….. Interventions for a patient with Decreased Interventions for a patient with Decreased activity/ mobility activity/ mobility • Establish individualized turning schedule. Establish individualized turning schedule. • Change position at least once in two hours and Change position at least once in two hours and more frequently for the high risk individuals. more frequently for the high risk individuals. Interventions for a patient with Poor nutrition Interventions for a patient with Poor nutrition • Provide adequate nutritional and fluid intake Provide adequate nutritional and fluid intake • Assist with intake as necessary. Assist with intake as necessary. • Consult dietitian for nutritional evaluation Consult dietitian for nutritional evaluation
ROLE OF NURSE….. • Evaluate the ulcer progress every 4 Evaluate the ulcer progress every 4- -6 days. • Assist the physician or surgeon in debridement Assist the physician or surgeon in debridement • Educate the patient and family regarding the Educate the patient and family regarding the risk factors and prevention of bed sores. risk factors and prevention of bed sores. 6 days.
