PRESSURE ULCER CARE

After 8 hours of classroom discussion and demonstration the Level IV nursing students
will be able to:
1. Define the following
1.1 pressure
1.2 pressure ulcer
1.3 pressure care
1.4 induration
1.5 erythema
1.6 maceration
1.7 debridement
1.8 exudates
2. explain the significance of ulcer care in relation to the nursing practice
3. distinguish different factors frequently act in conjunction with pressure to produce
pressure ulcer
4. recite some etiology in producing pressure ulcer
5. differentiate classification of bed sores
6. enumerate sign and symptoms of bed sores development
7. cite out the different techniques in preventing the development of bed sores
8. identify different treatments in bed sores
9. illustrate different types of dressings used for pressure ulcer
10. enumerate the guidelines in pressure ulcer care
11. state the different principles of infection control in patient with pressure ulcer
12. discuss the different nursing responsibilities before, during, and after pressure
ulcer care

1. Pressure - the continuous physical force exerted on or against an object by

something in contact with it.
2. Pressure ulcer- also called bed sores or decubitus ulcer

3.
4.
5.
6.
7.
8.

Are injuries to skin and underlying tissue resulting from

prolonged pressure on the skin. Bedsores most often develop
on skin that covers bony areas of the body, such as the heels,
ankles, hips and tailbone.
Pressure ulcer care- a nursing intervention defined as facilitation of healing in
pressure ulcers.
Induration- The hardening of a normally soft tissue or organ, especially the skin,
due to inflammation, infiltration of a neoplasm, or accumulation of blood.
Erythema- redness of the skin caused by congestion of the capillaries in the
lower layers of the skin. It occurs with any skin injury, infection, or inflammation.
Maceration- the softening and breaking down of skin resulting from prolonged
exposure to moisture.
Debridement- the removal of damaged tissue or foreign objects from a wound.
Exudate- A protein-rich fluid, such as serum or pus, that has leaked from blood
vessels or been discharged by cells or tissues.

Importance of pressure ulcer care

clean to prevent infection
Avoid further injury or friction
To prevent complications
To promote wound healing
To determine the stage of the ulcer
To promote comfort to the patient
To protect the wound and surrounding tissue

Factors frequently act in conjunction with pressure to produce

pressure ulcer
1 Friction
Force acting parallel to the skin surface
Can abrade skin removing the superficial layers more prone
2 Shearing Force
Combination of friction & pressure.
Fowlers position

Body tends to slide downward toward the foot of the bed


Transmitted to sacral bone & deep tissues

Skin over the sacrum, superficial tissues tends not to move

Deeper tissues are firmly attached to skeleton & move downward

Shearing force in the area where deeper tissues & superficial meet

Force damages the blood vessels & tissues in the area.

RISK FACTORS
1

4
5

Immobility
Reduction in control of movement person has.
Resulting from Paralysis, Extreme Weakness, Pain or any activity
that can hinder persons ability to move.
Inadequate Nutrition
Prolonged inadequate nutrition causes wt. loss, muscle atrophy, &
Inadequate intake CHON, CHO, Fluids, & Vit. C.
Hypoproteinemia dependent edema decreased elasticity,
vitality Injury
Edema increased distance between capillaries and cells
slowing O2 diffusion to cells & metabolites away from cells.
Fecal & Urinary Incontinence
Any accumulation of secretions or excretions in irritating to the
skin, harbor microorganisms & prone to skin breakdown & infection
Moisture from incontinence Skin Maceration (tissue softening
from prolonged soaking) epidermis more easily eroded &
increased risk for injury
Digestive enzymes in feces Skin Excoriation/Denuded Area
(area of loss of superficial layers)
Decreased Mental Status
Unconscious or Heavily Sedated because they are less able to
recognize & respond to pain assoc. with prolonged pressure
Diminished Sensation
Paralysis, Stroke, etc.
Decreases Persons ability to respond to injurious heat & cold & to
tingling sensation that signals loss of circulation.

6
7
8
9

Excessive Body Heat

Severe infection + increased Body temp. Affect the bodys ability
to deal with effects of tissue compression.
Advanced Age
Aging process brings about several changes in the skin making the
older person prone to impaired skin integrity.
Chronic Medical Conditions
Diabetes and cardiovascular disease compromise oxygen
delivery to tissues
poor perfusion
delayed healing
Other factor
Poor lifting and transferring techniques
Incorrect positioning
Hard support surfaces
Incorrect application of pressure-relieving devices

Etiology in producing pressure ulcer

Localized ischemia
(Deficiency in the blood supply to tissue)
(Tissue is caught between 2 hard surfaces-bed & bony skeleton-)

Blood cannot reach the tissues

Cells will be deprived of O2 & nutrients

Waste products of metabolism accumulate in the cells

Tissue dies

Damages to small blood vessels (prolonged)

Skin appears PALE

Relieved, REACTIVE HYPEREMIA (Bright Red flush)

(Bodys mechanism for preventing pressure ulcers, lasts - )

Flush d/t VASODILATION (extra blood floods to the area to compensate impeding blood
flow)

(-) redness, no tissue damage

(+) redness, tissue damage

Classification of bed sores

Stage I
The beginning stage of a pressure sore has the following characteristics:

The skin 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.

Stage II

The outer 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.

Stage III
the ulcer is a deep wound:

The loss 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.

Stage IV

A stage 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.

Unstageable
A pressure ulcer is considered unstageable if its surface is covered with yellow, brown,
black or dead tissue. Its not possible to see how deep the wound is.
Suspected Deep Tissue Injury
A purple or maroon localized area of discolored intact skin or blood-filled blister due to
damage of underlying soft tissue from pressure and/or shear. The area may be
preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to
adjacent tissue. A deep tissue injury may be difficult to detect in individuals with dark
skin tones. Evolution may include a thin blister over a dark wound bed. The wound may
further evolve and become covered by thin eschar. Evolution may be rapid exposing
additional layers of tissue even with optimal treatment.

Sign and Symptoms of Bed Sores Development

First signs

reddened, discolored or darkened area

It may feel hard and warm to the touch.
A pressure sore has begun if you remove pressure from the reddened area for 10
to 30 minutes and the skin color does not return to normal after that time.
Test your skin with the blanching test: Press on the red, pink or darkened area
with your finger. The area should go white; remove the pressure and the area
should return to red, pink or darkened color within a few seconds, indicating good
blood flow. If the area stays white, then blood flow has been impaired and
damage has begun.
Dark skin may not have visible blanching even when healthy, so it is important to
look for other signs of damage like color changes or hardness compared to
surrounding areas.

Different techniques in preventing the development of bed sores

Stage
1

Treatment goals
Protect the skin
and
remove the cause

II

Protect the skin

and
manage exudates;
closure and
regrowth
of skin

III and IV

Protect and keep

wound clean;
manage
exudates; and
reduce
wound size

intervention
Change position in bed or chair every two
hours.
Assess need for support surface.
Maintain head of bed at 30 degrees or less,
unless contraindicated.
Use draw sheet for repositioning.
Do not massage reddened areas.
Elevate heels off bed with pillow or protective
boots/splints.
Avoid positioning on affected area.
Manage exudates/moisture: Apply wound
dressing; change every 35 days and and
when needed.
None-to-light exudates: Ointment to affected
area, a thin wound dressing
Moderate-to-heavy exudates: Adhesive wound
dressing or a non-adhesive wound dressing
secured in place
Manage exudates/moisture: Apply a wound
dressing to create a moist wound environment,
which assists in autolytic debridement of
wounds covered with necrotic tissues
None-to-light exudates: Apply a thin wound
dressing or gel
Moderate-to-heavy exudates: Adhesive or nonadhesive wound dressing secured in place;
selection of dressing influenced by size and
location of the pressure ulcer; a rope or sheet
wound dressing may be needed in specific
situations or to pack the wound; change every
13 days and if needed, cover

different treatments in bed sores

Reposition patient every two hours

Clean wound with water and mild soap and pat dry
Apply dresssings

Surgical procedures

Surgical debridement involves cutting away dead tissue.

Mechanical debridement loosens and removes wound debris. This may be done
with a pressurized irrigation device, low-frequency mist ultrasound or specialized
dressings.
Autolytic debridement enhances 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 involves applying chemical enzymes and appropriate
dressings to break down dead tissue.

Pharmacological management

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.
Muscle relaxants such as diazepam (Valium), tizanidine (Zanaflex),
dantrolene (Dantrium) and baclofen (Gablofen, Lioresal) may inhibit
muscle spasms and help sores heal.

Different types of dressings used for pressure ulcer

1 Absorptive Dressings: These dressings are either applied directly to the wound or
on top of other primary dressings. Absorptive dressings are intended to remove the
drainage from the bed sore that may impede healing. Most absorptive dressings are
changed on a daily basis. However, excessive drainage from a bed sore may
require more frequent dressing changes.
Common types of Absorptive dressings include: Medipore, Silon Dual Dress, Aquacel
Hyrofiber Combiderm, Absorbtive Border, Multipad Soforb, Iodoflex, Tielle, Telefamax,
Tendersorb, Mepore and Exu-dry.
2 Alginates: Alginates are dressings made from fibers either completely or partially
made from seaweed or algae. Alginates absorb drainage from a bed sore and form a
gel-type barrier over the wound that ensures a moist environment to assist in healing
wounds. Alginates are commonly used in treating deep bed sores as they allow
wounds to heal even with dressings in the wound.
Common types of Alginates include: Algicell, Algisite, Carrasorb, Curasorb, Dermacea,
Dermaginate, fybron, Gentell, Kaltostat, Kalginate, Maxorb, Silvercell, Sorbsan,
Seasorb, Tegagen

3 Antimocrobials: In wound care, antimocribials refer to dressings that contain

antibacterial products or antibacterial creams used to reduce or kill bacteria in bed
sores. Before using antimocrobials, a physician must first determine if the bed sore
is infected. A bed sore can be tested for infection by doing a culture. In some
circumstances where a patient may be particularly at risk for developing an infection,
a physician may prescribe antimocrobials as a preventative measure.
Common types of Antimicrobials include: Tegaderm, Amerigel, Anasept, Silverton,
Contreet, Aquacel, Silverderm, Algidex, Colactive, Kerlix, Tefla, Arglase, Maxorb,
Optifoam, Acticoat,
4 Hydrocolloids / Hydrogels: Hydrocolloid dressings have gel-like properties and
absorb fluids from the wound. Because hydrocolloid dressings form a moistureproof barrier they frequently used with incontinent patients as they can keep urine
and feces out of the healing wounds. Hydrocolloids should be used in un-infected
bed sores. A physician should determine the frequency with which a hydrogel
dressing should be changed. Generally hydrogel dressings are changed from 2 to 7
times per week.
Common types of Hydrocolloid / Hydrogel dressings include: Tegagel, Biolex,
Carrasorb, Purilon, Repair Hydrogel, Dermasyn, Dermagran, Curasol, Restore, Nugel, Curafil, Skintegrity, Panoplex

Guidelines in pressure ulcer care

Use Aseptic Technique procedure

Wound cleansing should not be undertaken to remove 'normal' exudate
Cleansing should be performed in a way that minimizes trauma to the wound
Wounds are best cleansed with sterile isotonic saline or water
The less we disturb a wound during dressing changes the lower the interference
to healing
Fluids should be warmed to 37C to support cellular activity
Skin and wound cleansers should have a neutral pH and be non-toxic
Avoid alkaline soap on intact skin as the skin pH is altered, resistance to bacteria
decreases
Avoid delipidizing agents as alcohol or acetone as tissue is degraded
Antiseptics are not routinely recommended for cleansing and should only be
used sparingly for infected wounds

Principles of infection control in patient with pressure ulcer

Nursing responsibilities before, during, and after pressure ulcer care