Chapter 5 Assisting Clients With Hygiene Section 6 Prevention and Care of Pressure Ulcers
contents • Contributing Factors to Pressure Ulcers Formation • Prediction and Prevention of Pressure Ulcers • Treating and nursing pressure ulcer
Economic consequences of pressure ulcers • Frequency: • 3-14%,2-25%(nursing home) • 85.7% paraplegia • 58% pressure ulcer ＞ 65y • Economic consequences: • Days in hospital increase • Cost of heath care increase: $4,000-40,000
Pressure ulcer • decubitus ulcer, and bedsore • Concept: pressure sore, • a localized area of tissue lesion and necrosis that tends to develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period, blood circulation is obstructed, and local tissue is ischemic.
Contributing Factors to Pressure Ulcers Formation • Factor of pressure • Pressure • Friction • Shearing force • Moisture irritation to the Skin • Nutritional Status • Age • Fever (infection) • Orthopedic Devices
Factor of pressure 垂直 压力 Pressure 剪切力 Shearing force 摩擦力 Friction
Moisture irritation to the Skin • urinary and fecal incontinence • wound drainage • sweat
Nutritional Status • Malnutrition • Protein malnutrition • Protein- energy malnutrition • Cachexia • Obesity • Dehydration • Edema
Age Gerontologic nursing practices for the client with impaired skin integrity ★Older adult’s skin is less tolerant to pressure, friction, and shearing force because of decreased elasticity due to normal aging. ★The older adult has decreased number of sweat glands, leaving the skin dry and less tolerant to shear and friction. ★Impaired skin integrity is a high risk to older adult; it is among the five most common nursing diagnoses for older adult clients in long-term care facilities.
★Dermis of the older adult’s skin is thinner due to the normal absence of subcutaneous fat, therefore making the older adult more susceptible to skin breakdown. ★After the age of 50 epidermal cell renewal reduces by one third, and as a result wound healing is approximately 50% slower than a 35-year-old adult. ★In the presence of chronic coronary or peripheral vascular diseases circulation to the extremities is reduced.
Fever (infection) • increase the body’s metabolic rate • increasing the needs of the cells for oxygen • Make hypoxemic tissue more susceptible to ischemic injury • diaphoresis • increased skin moisture irritation
Orthopedic Devices • plaster, bandage, splint, retractor • reduce mobility of the client or of an extremity • friction • pressure
Prediction and Prevention of Pressure Ulcers • Assessment • Patients With High Risk of Pressure Ulcers • Predicting Pressure Ulcers Risk • Common Pressure Ulcer Sites • Preventative interventions
Patients With High Risk of Pressure Ulcers! • Clients with the neural diseases • Old people • Obesity • Debilitated and malnutrition • Edema • Pain • orthopedic devices • urinary and fecal incontinence • fever • quietive therapy
Predicting Pressure Ulcers Risk • predictive instruments • the Braden Scale • the Norton Scale • the Gosnell and Knoll instruments
Common Pressure Ulcer Sites bony prominences
1965年Indan等通过研究报告了人在坐和卧位时压迫点的分布，仰卧时，枕骨粗隆、骶尾部、足跟是压迫最重的部位，压力范围5.3～8.0kPa(40～60mmHg)。1965年Indan等通过研究报告了人在坐和卧位时压迫点的分布，仰卧时，枕骨粗隆、骶尾部、足跟是压迫最重的部位，压力范围5.3～8.0kPa(40～60mmHg)。 • 俯卧时膝部和胸部受到的压力接近6.7kPa(50mmHg) • 坐位时,集中到坐骨结节的压力高达10kPa(75mmHg)。
肩胛部 枕部 骶尾部 足跟部 肘部 supine position spine carina 脊椎 Occipital scapula heel sacrum elbow
踝部 髋部 肩峰 耳部 内髁与 外 髁 肘部 Lateral position Medial, lateral malleolus ear medial,lateral knee shoulder anterior iliac crest elbow
面颊和 耳 廓 生殖器 （男性） 乳房 （女性） 足趾 肩峰 膝 部 Prone position breast(female) breast(female) genitals(male) iliac crest, knee cheek (ear) shoulder knee toes Genitals (male) Breast (female) iliac crest
Sitting position shoulder elbow sacrum ischium tuber sole
Preventative interventions • Avoid pressure on local tissues for prolonged period • Reduce shear and friction • Protect skin of patients (Hygiene and skin care) • Stimulating blood circulation of skin • Provide adequate nutrition • Health education
Avoid pressure on local tissues for prolonged period • Turn the patients periodically (every 2 hours or 30 minutes necessarily) • Protect bony prominence and support interspace • Use the devices right, such as plaster, bandage, splint, retractor
翻身 Avoid pressure on local tissues in prolonged period • Turn the patients periodically • Protect bony prominence and support interspace • Use the devices right 支被架 气垫床褥
Devices used to prevent or treat pressure ulcers Devices to support pressure areas Flotation pads are pliable pads with a consistency like body fat, which disperse pressure over a larger area. Pillows and bridging techniques lift the pressure site off the mattress and separate two points of pressure. Devices to aid in turning a client A Guttman bed rotates the client from prone to supine positions and from side to side. Kinetic therapy continuously rotates the client 270 degrees every 3 minutes.
Devices to minimize or equalize pressure Alternating air mattresses made of polyvinyl air cells are attached to a pump that inflates and deflates them every 3-7 seconds, alternating pressure points. Water mattresses disperse and evenly distribute the client’s body weight. High and low air loss bed allow deformation of bed surface to the body contours, thereby reducing tissue pressure below capillary closure. These beds also eliminate shear and friction and reduce moisture.
Reduce shear and friction • For bedridden clients, elevated the head of the bed to no more than 30 degrees. • clients must be positioned, transferred, and turned correctly. • lifting rather than dragging • bedpan
Protect skin of patients • keep the client’s skin and bedsheet clean and dry • Clean,not soap ; daub ointments, • Urine, stool, wound drainage;Vaseline or zinc oxide • Incontinence; diaper
Stimulating blood circulation of skin • range-of-motion,ROM • Warm water bath in bed: see disc • Check and massage skin • Local tissue massage • back rub: see disc
Provide adequate nutrition • receive sufficient protein, vitamins (A, C, B1, B 5), and zinc
Health education • Educate clients and care givers regarding pressure ulcer prevention
Stages of Pressure Ulcer • Stage I :nonblanchable erythema of intact skin, the heralding lesion of skin ulceration • Stage Ⅱ: Partial thickness skin loss involves damage or necrosis of epidermis, dermis, or both • Stage Ⅲ: Full thickness skin loss involves damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia • Stage Ⅳ: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structure such as tendon or joint capsule
瘀血红润期（hyperemia, nonblanchable erythema ） • heralding lesion. • temporary circulation lesion • Manifestation: • Redness(lightly skin) • Red blue,purple hues (darker skin) • Redness, swollenness, heat, and pain
炎性浸润期(ischemic,inflamation ) • epidermis, dermis, or both • Gore,ischemic, • readness and swollenness enlarged；color: purple, not change with pressed；superficial abrasion, blister or shallow crater
浅度溃疡期(superficial ulceration) • subcutaneous tissue(superficial tissue) • Blister is torn,infection, ichor,necrosis and ulcer
坏死溃疡期(Necrotic ulceration) • Deep dermis, muscle, bone, tendon or joint capsule • Necrosis turn blue,ichor, septicopyaemia
Treating pressure ulcer • Supportive or systemic measures： • providing adequate nutrition • Protein status • Hemoglobin • Controlling infection： • Body substance isolation and good hand washing technique • Local care of the wound
Local care of the wound • Stage I • Principle: eliminating risk factors or contributing factors to pressure ulcers • increasing turning frequency, avoiding local tissue pressed long term, improving circulation, keeping bed linen clean, smooth, dry without oddment, reducing friction and shearing force, avoiding excretion and moisture stimulating to skin, increasing nutrition and enhancing immunity and so on. • Moist dressing • Toast light • Ban massage
Stage Ⅱ • Principle:protecting skin and preventing infection • preventive measure followed • intensify care of blister • Small untorn blister: • big blister: see disc • draw out liquid in blister with sterile injector , unnecessarily scissoring pellicle, and then sterilize the surface and cover it with sterile dressings. • ultraviolet or infrared treatment.
Stage Ⅲ • Principle:keeping cleanliness of the ulcer area • Eliminate pressure,keep clean • physical therapy: Goosenecked light • Moisture-retentive dressings • transparent films, hydrocolloid dressing, and hydrogels • 新鲜的鸡蛋内膜、纤维蛋白膜、骨胶原膜等贴于创面
Stage Ⅳ • Principle:keeping cleanliness of the ulcer area, debriding necrotic tissue, keeping drainage smoothly, promoting acestoma growing
Stage Ⅳ • Preventive measures • Clean and rinse ulcer area: see disc • with sterilized normal saline or 1:5000 Furacilin solution, then covered with sterilized Vaseline gauze or dressings. Metronidazole dressing or be daubed with Sulfapyridine Argentums or Furacilin. • cleansed with 3% Hydrogen Peroxide solution for deep ulcer. • keeping drainage smoothly • oxygen therapy • Surgery: debride necrotic tissue, skin grafting and skin flap • Chinese traditional medicine
Key term • Pressure ulcer, pressure sore, decubitus ulcer, and bedsore • Contributing Factors to Pressure Ulcers Formation • Pressure • Friction • Shearing force • Moisture • incontinence
Malnutrition • obesity • Cachexia • Dehydration • Edema • hypoxemic • ischemic • Orthopedic Devices
plaster, bandage, splint, retractor • hypoalbuminemia • Mobility • Activity • Apathetic • Bedfast • Occipital bone, scapula, spine carina, elbow, iliac crest, sacrum, heel