PRESSURE ULCER

Pressure ulcers - Are localized areas of dead soft tissue that occurs when pressure applied to the skin overtime is more than 32 mmHg leading to tissue damage

INITIAL SIGN OF PRESSURE ULCER:

• ERYTHEMA or redness of the skin that DOES NOT blanch

Weight bearing Bony prominences
1. Sacrum and cocygeal area
2. Ischial tuberosity
3. Greater trochanter
4. Heel and malleolus
5. Tibia and fibula
6. Scapula and elbow

Risk Factors:
1. Patients with sensory deficits
2. Decreased tissue perfusion
3. Decreased nutritional status
4. Friction and shearing forces
5. Increased moisture and edema

STAGES OF PRESSURE ULCER:
Stage 1- non-blanchable Erythema
Stage 2- skin breakdown in dermis
Stage 3- ulceration extends to the subcutaneous tissue
Stage 4- ulcers involve the muscle and bone

NURSING INTERVENTIONS:
1. RELIEVE THE PRESSURE

• Turn and reposition every 1-2 Hours
• Encourage weight shifting actively, every 15 minutes

2. POSITION PATIENT PROPERLY

• Follow the recommended sequence
• Lateralà proneà supineà lateral
• Position patient with the bed elevated at NO MORE THAN 30 degrees
• Utilize the bridging technique

3. UTILIZE PRESSURE RELIEVING DEVICES

• Use floatation pads
• Use air, water or foam mattresses
• Oscillating and kinetic bed

4. IMPROVE MOBILITY

• Active and passive exercises
• Assistive exercise

5. IMPROVE TISSUE PERFUSION

• Exercise and repositioning are the most important activities
• AVOID MASSAGE ON THE REDDENED AREAS

6. IMPROVE NUTRITIONAL STATUS

• HIGH protein
• HIGH vitamin C diet
• Measure body weight
• Assess hemoglobin and albumin

7. REDUCE FRICTION AND SHEAR

• Lift and not drag patient
• Prevent the presence of wrinkles and creases on bed sheets

8. REDUCE IRRITATING MOISTURE

• Adhere to a meticulous skin care
• Promptly clean and dry the soiled areas
• Use mild soap and water
• Pat dry and not rub
• Lotion may be applied
• AVOID powders (cause dryness)

9. PROMOTE WOUND HEALING

• Vitamin C
• Dictum: Remove the pressure

Stage 1

• Remove pressure
• Reposition Q 2
• Never massage the area

Stage 2

• Clean with sterile SALINE only
• Antiseptic solutions may damage healthy regenerating tissue and delay healing
• Wet saline dressings are helpful

Stage 3 and 4

• Necrotic tissues are debrided
• Administer analgesics before cleansing
• Do a mechanical flushing with saline solution
• Topical ointments may be applied UNTIL granulation tissue appears then only saline irrigation is recommended

 QUOTE OF THE DAY!