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Pressure Ulcer Staging and Prevention Guide

Pressure ulcers, also known as bedsores or decubitus ulcers, are caused by unrelieved pressure on the skin and underlying tissues. They are most common in immobile patients and are staged based on the depth of tissue damage, from non-blanchable erythema to full thickness tissue loss. Prevention focuses on reducing pressure through frequent repositioning, special mattresses, and mobility when possible. Treatment involves dressing wounds appropriately and addressing nutritional and moisture issues.

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554 views44 pages

Pressure Ulcer Staging and Prevention Guide

Pressure ulcers, also known as bedsores or decubitus ulcers, are caused by unrelieved pressure on the skin and underlying tissues. They are most common in immobile patients and are staged based on the depth of tissue damage, from non-blanchable erythema to full thickness tissue loss. Prevention focuses on reducing pressure through frequent repositioning, special mattresses, and mobility when possible. Treatment involves dressing wounds appropriately and addressing nutritional and moisture issues.

Uploaded by

twy113
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd

Pressure Ulcer

Ella Yu (VL)
Pressure Ulcer
 Decubitus ulcers, pressure sores or bedsores
 Caused by unrelieved pressure
Etiology
 Due to localized ischemia
 Deficiency in the blood supply to the tissue
 Reactive hyperemia (bright red flush)
 Vasodilation- compensate for the preceding period of
impeded blood flow
Two factors:
 Friction
 Shearing force
Pressure Ulcers
Risk factors:
 Immobilty
 Inadequate nutriition: hypoprotenemia, oedema
 Fecal and urinary incontinence: maceration and
excoriation
 Decreased mental status
 Diminshed sensation
 Excessive body heat
 Advanced age
 Chronic medical condition
 Other factors
Stages of pressure ulcer
formation
Stage 1: nonbalnchable erythema
Stage 2: Partial thickness loss
Stage 3: Full-thickness skin loss
Stage 4: full-thickness skin loss with tissue
necrosis or damage to muscle, bone
or supporting structures
Figure 34.1 Four stages of pressure ulcers. (1 of 4)
Figure 34.1 Four stages of pressure ulcers. (2 of 4)
Figure 34.1 Four stages of pressure ulcers. (3 of 4)
Figure 34.1 Four stages of pressure ulcers. (4 of 4)
Figure 34.2 Body pressure areas in A, supine position; B, lateral position; C, prone position; D, Fowler’s position.
Nursing Intervention
 Maintain skin integrity
 Prevention of pressure sore

 Treating pressure sore


 Use appropriate dressing materials
Prevention of Pressure Ulcers
 Routine Systematic Skin Assessment
 Inspect the skin head-to-toe in adequate light at
least once a day
 Teach patients and family members to inspect
susceptible parts visually and by touch
Assessment of skin integrity
 Assessment of the body pressure areas
 Norton’s Pressure Area Risk Assessment Form
Scale
 Scores of 15or 16 as indicators of risk
 Braden scale
 A total of 23 points
 15-18 points is considered at risk
 13-14 points- moderate risk
 10-12 points- high risk
 9 or less- very high risk
Assessment of skin integrity
Documentation
 Location of the lesion
 Size of lesion
 Presence of undermining or sinus tract
 Stage of ulcer
 Colour of the wound bed and location of the necrosis or
eschar
 Condition of the wound margins
 Integrity of surrounding skin
 Clinical signs of infection
Prevention of Pressure Ulcers
 Routine Systematic Skin Assessment
 Inspect the skin head-to-toe in adequate light at
least once a day
 Teach patients and family members to inspect
susceptible parts visually and by touch
Prevention of Pressure Ulcers
 Reduce Exposure to Pressure
 Frequent Patient Turning
 Relieve pressure on sensitive areas by turning at
least every __ hours. Some patients may need to be
turned more frequently
 Use a written turn schedule

 Encourage chair-fast patient to shift position every


______ minutes
Turning Schedule
2-hrly turning

300 tilt at lateral


position

Use positioning
devices

(Potter & Perry, 1997)


Prevention of Pressure Ulcers
 Reduce Exposure to Pressure
 Appropriate Patient Positioning
 Use positioning devices to keep bony prominences
from direct contact with each other
 Keep heels off the bed with a positioning device
 Avoid 90 degree lateral lying position
 Utilize ___ degree oblique side lying position
 Maintain patient in proper alignment both in bed and
chair
 Avoid positioning patient on pressure ulcer
Prevention of Pressure Ulcers
 Reduce Exposure to Pressure
 Pressure Reducing Surfaces
 Apply protective padding at bony prominences
 _____________, ________________
 Use pressure reducing mattress
 foam, alternating pressure mattress, gel or water bed,
air-fluidized bed
 Use pressure relieving cushions for chair- or
wheelchair-bound patients
 Pad casts and cast edges

 Pad oxygen tubing around the ears


Mechanical devices for reducing
pressure on body parts
 Gel flotation pads
 Sheepskins
 Pillow and wegdes
 Heel protectors
 Egg crate mattress
 Foam mattress
 Alternating pressure mattress
 Water bed
 Air- fluidized bed (static high –air-loss bed)
 Static low-air-loss bed
 Active LAL bed
Sheepskins heel protector
Pressure relieving devices
Ankle off the bed
Heels off the bed
Egg crate mattress
Alternating pressure mattress: uses a pump to increase or decrease the pressure
Low-air-loss bed: air-filled cushions into 4 or 5 sections- different level of firmless.
reduce pressure at bony promenences site but increase other
body area support
Air-fluidized bed (astatic high-air-loss bed):
Forced temperature- controlled air is circulated around millions of tiny
Silicon –coated beads, producing a fluidlike movement and provide uniform
support to body contour
Prevention of Pressure Ulcers
 Improve Mobility and Activity Levels
 ___________________________

 ___________________________

 Avoid over sedation and inactivity


 Avoid restraints
Prevention of Pressure Ulcers
 Reduce Excessive Moisture
 _____________________________

 _____________________________

 _____________________________

 _____________________________
 ______________________________

 ______________________________

 Change wound dressing when needed

 Pouch heavily draining wounds


Prevention of Pressure Ulcers
 Minimize Skin Dryness
 ___________________________

 ___________________________

 ___________________________

 ___________________________

 ___________________________
Prevention of Pressure Ulcers
 Prevent Friction and Shear
 Avoid elevating the head of the bed more than
30 degrees unless medically inappropriate
 Utilize a trapeze, bed linen and other
positioning devices to avoid sliding and
dragging patients across bed and chair
surfaces while repositioning
 Protect heels and elbows
 Use soft, clean and wrinkle-free sheets
 Apply protective film dressings
 Pat dry, do not rub with towel
Prevention of Pressure Ulcers
 Improve Nutrition
A well-balanced diet with sufficient protein and
calorie content
 Vitamin supplements containing vitamin C,
vitamin A, and zinc
 Improve suboptimal food intake

 Improve fluid intake


Prevention of Pressure Ulcers
 Education
 Health care professionals
 Caregivers

 Patients
Treating of pressure ulcer
 Focus of pressure ulcer treatment:
 local care of the wound
 Wound dressing

 Choice of appropriate wound dressing material


 Transparent adhesive films, hydrogels, hydrocolloids, alginates
 supportive measures, e.g. adequate nutrition, relief of
pressure
Treatment of pressure ulcer

(Kozier, Erb, Berman, & Burke, 2000)


Pressure sore is preventable
Florence Nightingale (1861) ….

Saw pressure sore as


the fault of the nurses
rather than the disease.
Pressure sore is preventable

Nursing accountability

•Inadequate assessment

•Inappropriate prevention and


management

•Inappropriate choice of dressing

•Improper documentation
Reference
 Kozier, B., Erb, G., Berman, A. J., & Burke, K. (2000).
Fundamentals of nursing: Concepts, process, and practice.
(6th ed.). New Jersey: Prentice Hall Health.
 Kozier, B., Erb, G., Berman, A., & Snyder, S. (2004).
Fundamentals of nursing: Concepts, process, and practice.
(7th ed.). New Jersey: Prentice Hall.
 Potter, P. A., & Perry, A. G. (1997). Fundamentals of nursing:
Concepts, process, and practice. (4th ed.). St. Louis: Mosby.
 Taylor, C., Lillis, C., & LeMone, P. (2001). Fundamentals of
nursing: The art & science of nursing care. (4th ed.).
Philadelphia: Lippincott.
Q&A

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