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Pressure ulcer
- 1.
- 2. Pressure ulcer —also called pressure sores or Bed sores or decubitus ulcer — are injuries to skin and underlying tissue resulting from prolonged pressure on the skin.
- 4. • Bedsores mostoften develop on skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone. • People most at risk of bedsores are those with a medical condition that limits their ability to change positions, requires them to use a wheelchair or confines them to a bed for a long time.
- 5. CAUSES • Bedsores arecaused by pressure against the skin that limits blood flow to the skin and nearby tissues. • Other factors related to limited mobility can make the skin vulnerable to damage and contribute to the development of pressure sores.
- 6. Three primary contributingfactors are: • Sustained pressure. When the skin and the underlying tissues are trapped between bone and a surface such as a wheelchair or a bed, the pressure may be greater than the pressure of the blood flowing in the tiny vessels (capillaries) that deliver oxygen and other nutrients to tissues. Without these essential nutrients, skin cells and tissues are damaged and may eventually die.
- 7. • This kindof pressure tends to happen in areas that aren't well-padded with muscle or fat and that lie over a bone, such as spine, tailbone, shoulder blades, hips, heels and elbows.
- 8. • Friction. Friction isthe resistance to motion. It may occur when the skin is dragged across a surface, such as when change position or a care provider moves the patient. The friction may be even greater if the skin is moist. Friction may make fragile skin more vulnerable to injury.
- 9. • Shear. Shear occurswhen two surfaces move in the opposite direction. For example, when a hospital bed is elevated at the head, you can slide down in bed. As the tailbone moves down, the skin over the bone may stay in place — essentially pulling in the opposite direction. This motion may injure tissue and blood vessels, making the site more vulnerable to damage from sustained pressure.
- 10. RISK FACTORS People areat risk of developing pressure sores if they have difficulty moving and are unable to easily change position while seated or in bed. Immobility may be due to: – Generally poor health or weakness – Paralysis – Injury or illness that requires bed rest or wheelchair use – Recovery after surgery – Sedation – Coma
- 11. Other factors thatincrease the risk of pressure sores include: • Age. The skin of older adults is generally more fragile, thinner, less elastic and drier than the skin of younger adults. Also, older adults usually produce new skin cells more slowly. These factors make skin vulnerable to damage. • Lack of sensory perception. Spinal cord injuries, neurological disorders and other conditions can result in a loss of sensation. An inability to feel pain or discomfort can result in not being aware of bedsores or the need to change position.
- 12. • Weight loss. Weightloss is common during prolonged illnesses, and muscle atrophy and wasting are common in people with paralysis. The loss of fat and muscle results in less cushioning between bones and a bed or a wheelchair. • Poor nutrition and hydration. People need enough fluids, calories, protein, vitamins and minerals in their daily diet to maintain healthy skin and prevent the breakdown of tissues.
- 13. • Excess moistureor dryness. Skin that is moist from sweat or lack of bladder control is more likely to be injured and increases the friction between the skin and clothing or bedding. Very dry skin increases friction as well. • Bowel incontinence. Bacteria from fecal matter can cause serious local infections and lead to life- threatening infections affecting the whole body.
- 14. • Medical conditionsaffecting blood flow. Health problems that can affect blood flow, such as diabetes and vascular disease, increase the risk of tissue damage. • Smoking. Smoking reduces blood flow and limits the amount of oxygen in the blood. Smokers tend to develop more-severe wounds, and their wounds heal more slowly.
- 15. • Limited alertness. Peoplewhose mental awareness is lessened by disease, trauma or medications may be unable to take the actions needed to prevent or care for pressure sores.
- 16. PATHOPHYSIOLOGY Continuous external pressureover the soft tissue between the boney prominence and hard surface may cause compression of the capillaries and cause impairment of blood flow. When the pressure continuous the platelets will get aggregated in the capillaries and forms microthrombi.
- 17. • The thrombiwhich was formed in the capillaries will increase the resistance , ischemia and hypoxia, which will eventually leads to tissue death and necrosis.
- 18. CLINICAL FEATURES • Pain •Localized edema • Blister formation • Formation of lesion • Tissue necrosis • Erythema • Warmness around the inflamed area
- 19. STAGES STAGE I • Theskin is not broken. • The skin appears red on people with lighter skin color, and the skin doesn't briefly lighten (blanch) when touched. • On people with darker skin, the skin may show discoloration, and it doesn't blanch when touched. • The site may be tender, painful, firm, soft, warm or cool compared with the surrounding skin.
- 20. Stage II • Theouter layer of skin (epidermis) and part of the underlying layer of skin (dermis) is damaged or lost. • The wound may be shallow and pinkish or red. • The wound may look like a fluid-filled blister or a ruptured blister.
- 21. Stage III • Theloss of skin usually exposes some fat. • The ulcer looks crater-like. • The bottom of the wound may have some yellowish dead tissue. • The damage may extend beyond the primary wound below layers of healthy skin.
- 22. Stage IV • Astage IV ulcer shows large-scale loss of tissue: • The wound may expose muscle, bone or tendons. • The bottom of the wound likely contains dead tissue that's yellowish or dark and crusty. • The damage often extends beyond the primary wound below layers of healthy skin.
- 23. DIAGNOSIS • Proper historycollection • Physical examination • Diagnosis is made from clinical features • Blood studies include protein, albumin and hemoglobin and it helps to find out any signs of malnutrition • Bone studies helps to identify the signs of involvement of bones.
- 24. TREATMENT Stage I andII bedsores usually heal within several weeks to months with conservative care of the wound and ongoing, appropriate general care. Stage III and IV bedsores are more difficult to treat.
- 25. • The firststep in treating a bedsore is reducing the pressure that caused it. Strategies include the following: – Repositioning. If patient have a pressure sore, you need to be repositioned regularly and placed in correct positions.
- 26. • Using supportsurfaces. Use a mattress, bed and special cushions that help you lie in an appropriate position, relieve pressure on any sores and protect vulnerable skin.
- 27. Cleaning and dressingwounds • Cleaning. It's essential to keep wounds clean to prevent infection. If the affected skin is not broken (a stage I wound), gently wash it with water and mild soap and pat dry. Clean open sores with a saltwater (saline) solution each time the dressing is changed.
- 28. • Applying dressings. Adressing promotes healing by keeping a wound moist, creating a barrier against infection and keeping the surrounding skin dry. Dressing choices include films, gauzes, gels, foams and treated coverings.
- 29. Removing damaged tissue •Surgical debridement it involves cutting away dead tissue. • Mechanical debridement in this loosens and removes wound debris. This may be done with a pressurized irrigation device, low-frequency mist ultrasound or specialized dressings.
- 30. • Autolytic debridement itenhances the body's natural process of using enzymes to break down dead tissue. This method may be used on smaller, uninfected wounds and involves special dressings to keep the wound moist and clean. • Enzymatic debridement it involves applying chemical enzymes and appropriate dressings to break down dead tissue.
- 31. Other interventions • Painmanagement. Pressure ulcers can be painful. Nonsteroidal anti-inflammatory drugs — such as ibuprofen (Motrin IB, Advil, others) and naproxen (Aleve, others) — may reduce pain. • Antibiotics. Infected pressure sores that aren't responding to other interventions may be treated with topical or oral antibiotics.
- 32. • A healthydiet. To promote wound healing, doctor or dietitian may recommend an increase in calories and fluids, a high-protein diet, and an increase in foods rich in vitamins and minerals.
- 33. NURSING MANAGEMENT • Assessthe specific risk factors for pressure ulcer. • Determine the client’s age and general condition of the skin. • Assess the client’s nutritional status, including weight, weight loss, and serum albumin levels, if indicated.
- 34. • Assess theskin on admission and daily for an increasing number of risk factors. • Assess for a history of radiation therapy. • Assess the client’s awareness of the sensation of pressure. • Assess for fecal and urinary incontinence. • Assess client’s ability to move
- 35. • Assess thesurface that the clients spend a majority of time on. • Assess the client’s level of pain, especially related to dressing change and procedures.