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Pressure Ulcer DR Mirfat
Pressure Ulcer DR Mirfat
and
Management
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c. Diabetes
d. Having Pneumonia
e. Having a cane – she’ll beat the nurses up!
Three Layers
Epidermis
Outermost Layer
Contains sensory receptors for pain,
temp, touch, vibration, and pressure
detection
Barrier to preserve moisture,
vitamins, minerals, and proteins
Dermis
Lies beneath the epidermis, deeper
and thicker too
Contains connective tissue, &
sebaceous glands
Contains fat &sweat glands
Subcutaneous Tissue
Layer of fat and connective tissue
Layer of insulation to conserve body
heat
National Pressure Ulcer Advisory Panel (2007).
Lippincott Williams and Wilkins, 2011 For Educational Purposes.
Also known as: Pressure/Bed
Sores
Definition:- Areas of cellular
necrosis and skin breakdown
most common over bony
prominences
Can occur anywhere on the
body
Most Common Sites: Sacrum,
Heels
Lippincott Williams and Wilkins, 2011
Extrinsic Factors
Pressure
Friction
Shearing
Intrinsic Factors
Immobility
Inactivity
Incontinence
Malnutrition
Age
Mental Status
Mereck Manual of Geriatrics, 2000
BEGINS ON ADMISSION
Skin Exam
On admission and every shift
History of Pressure ulcers
Recent weight loss
Mobility Status
Urinary/Bowel Incontinence
Dietary Intake/nutrition Status
Use Scales For Assessment
Braden Scale -Norton Scale -PUSH Tool
• Used to accurately predict who will develop pressure ulcers
• 6 Areas of Assessment: Sensory Perception, Activity,
Mobility, Skin Moisture, Nutritional Intake, Friction and
Shear
• At Risk (15-18)
• Moderate Risk (13-14)
• High Risk (10-12)
• Very High Risk (9 or below)
Cassell, 2009.
BEGINS AT FIRST CONTACT
Turn patient at least every 2 hours
Do not place patient in a 90 degree lateral position
Puts more pressure on greater trochanter and
lateral malleolus
Don’t elevate head of bed > 30 degrees (except
when eating) to minimize shearing forces
Avoid Fluorescent Light, it casts a blue tint to skin
Check skin of high risk patients for changes in:
Color, turgor, temperature, and sensation.
Patient should not sit more than 2 hours
Sitting position puts increased pressure on ischial
tuberosities.
Reposition patient every hour in chair
Teach patient to shift weight every 15 minutes
Do not use pillows/ rubber doughnuts
Keep skin surface clean and dry (Meticulous skin care)
As few pads as possible should be used
Main Points:
Keep pressure off the area of breakdown
Clean and dress the wound
Maintain good nutrition
Monitor Lab Values:
HgB <12
Total Lymphocyte Count <1200
Serum Albumin <3.5
Serum Transferrin <170
6 Stages
Staged according to
depth of damage
Abrass, 2004
An area of intact skin that does
not blanch and is usually over a
bony prominence.
NON-BLANCHABLE
Abrass, 2004
Friction: Surface damage caused by skin rubbing against
another surface.
Shearing: Trauma to skin caused by tissue layers sliding against each other,
results in disruption of blood vessels.
Maceration: Softening of tissue by soaking in fluids.
Debridement: Removal of damaged tissue.
Eschar: Thick, leathery necrotic tissue; damaged tissue.
Slough: Loose, stringy necrotic tissue
Undermining: Tissue destruction underlying intact skin
along wound edges.
Tunneling: A narrow channel/passageway extending into
healthy tissue.
c. Maceration
d. Laceration
Click Here To Read
Case Study Narrative
Hulse, 2011
Account for 20% of all
pressure ulcers
Easy to acquire hard to heal
Pressure relief
Pillows (floating)
Heel Protector Boots
Dressing if necessary
Foam Pads
Lippincott Williams and Wilkins, 2011 Mereck Manual of Geriatrics, 2000; Capezuti, 2008
Prevention Strategies
Pressure Reduction
Avoiding Friction/ Shearing
Forces
Stage III/IV
Debridement of necrotic tissue
Freq Irrigation (2-3x/d)
Dressing of the wound
Encourage movement
c. Venous Insufficiency
d. Lack of Mobility
e. None of the Above
f. All of the Above
Press ulcers can increase
morbidity and risk for
complications
Grace represents a typical
patient
Documentation and thorough
assessment is a necessity