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    Pressure Ulcer

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    enam professor
    1. Pressure ulcers develop from prolonged pressure that reduces blood flow to the skin and underlying tissues, most often over bony prominences. 2. They are staged from I to IV based on the depth of tissue destruction, from non-blanchable redness to full thickness tissue loss with exposed bone or muscle. 3. Prevention focuses on frequent position changes, support surfaces, nutrition, and managing incontinence to reduce pressure and moisture on the skin. 4. Treatment involves changing positions, dressings, debridement of damaged tissue, and sometimes surgery for severe cases.

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    Pressure Ulcer

    Uploaded by

    enam professor
    332 views35 pages
    1. Pressure ulcers develop from prolonged pressure that reduces blood flow to the skin and underlying tissues, most often over bony prominences. 2. They are staged from I to IV based on the depth of tissue destruction, from non-blanchable redness to full thickness tissue loss with exposed bone or muscle. 3. Prevention focuses on frequent position changes, support surfaces, nutrition, and managing incontinence to reduce pressure and moisture on the skin. 4. Treatment involves changing positions, dressings, debridement of damaged tissue, and sometimes surgery for severe cases.

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    Pressure ulcer

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    1. Pressure ulcer

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    1. Pressure ulcers develop from prolonged pressure that reduces blood flow to the skin and underlying tissues, most often over bony prominences. 2. They are staged from I to IV based on the depth of tissue destruction, from non-blanchable redness to full thickness tissue loss with exposed bone or muscle. 3. Prevention focuses on frequent position changes, support surfaces, nutrition, and managing incontinence to reduce pressure and moisture on the skin. 4. Treatment involves changing positions, dressings, debridement of damaged tissue, and sometimes surgery for severe cases.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    332 views35 pages

    Pressure Ulcer

    Uploaded by

    enam professor
    1. Pressure ulcers develop from prolonged pressure that reduces blood flow to the skin and underlying tissues, most often over bony prominences. 2. They are staged from I to IV based on the depth of tissue destruction, from non-blanchable redness to full thickness tissue loss with exposed bone or muscle. 3. Prevention focuses on frequent position changes, support surfaces, nutrition, and managing incontinence to reduce pressure and moisture on the skin. 4. Treatment involves changing positions, dressings, debridement of damaged tissue, and sometimes surgery for severe cases.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 35

    PRESSURE

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

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