Pressure Ulcer

Diagnostic Evaluation
1. No testing is usually indicated.
2. Wound cultures are usually inaccurate due to bacterial contamination and
colonization, but may be done to guide antibiotic therapy when signs of infection
are present.
Therapeutic Interventions
1. Pressure must be relieved and maceration, friction and shearing forces avoided
for wound healing to take place.
2. Normal saline is used for routine cleansing once to several times daily depending
on the amount of wound drainage, unless a protective dressing is used.
3. Wet to dry dressings may be used to assist with mechanical debridement.
4. Debridement of devitalized tissue may be necessary using scissors and scalpel
following sterile technique.
5. Protective wound dressings may be used to minimize disruption of migrating
fibroblasts and epithelial cells and to provide moist, nutrient rich environment for
healing.
Pharmacologic Interventions
1. Debriding enzymes may be used for stage III to IV ulcers; may damage healthy
tissue and are not appropriate for hard eschar.
2. Topical antibiotics may be used to treat signs of local wound infection.
3. Analgesics are usually needed, particularly 30 to 60 minutes before wound care.
Nursing Interventions
1. Monitor for signs of local infection (erythema around edges, foul odor, purulent
exudates, poor healing) as well as sepsis (fever, cellulites around wound,
increased pain, decreased blood pressure, tachycardia, altered level of
consciousness).
2. Assess size of pressure sore weekly in response to therapeutic measures;
document the largest diameter, not just the surface diameter, and document the
greatest depth.
3. Monitor pain level and response to pain medication; in unresponsive patient, look
for agitation, tachycardia and increased blood pressureto indicate pain.
4. Use pressure0 reducing surface to help prevent pressure sores, but they are not
effective in treating established pressure sores.
5. Avoid elevating head of the bed more than 30 degrees to prevent shearing force as
the patient slides downward against mattress.
6. Encourage activity and ambulation as much as possible.
7. Turn and reposition patient every 2 hours.
8. Bathe patient as needed with a bland soap, rinse, and blot dry with a soft towel.
9. Lubricate skin at least twice daily with a bland cream or gel, especially
over pressure points.
10. Employ bowel and bladder program to prevent incontinence.
11. Avoid plastic coverings and poorly ventilated chair or mattress surfaces.
12. Ensure that high protein, nutritious diet is provided, utilize supplements as
necessary and ensure adequate fluids to hydrate skin.
13. Clean pressure sore, as directed or per protocol; use normal saline or
prescribed solution, irrigate as necessary to remove exudates, but do not disrupt
healing tissue.
14. Teach diet rich in protein, iron, and vitamin C to aid in full healing.