Prepared by GF Lim

Fundamental of Nursing I
July 2009 Semester

Previously known as pressure sores or

bedsores.
Pressure ulcer is an lesion caused by
unrelieved pressure that results in damage to
underlying tissue.
This unrelieved pressure caused ischemic
hypoxia of the tissue as compromised on the
blood supply.
This can happen in acute setting and longterm care setting.

Pressure ulcer usually located

over the bony prominence,
where normal tissue is squeezed
between the bone and pressure
or friction caused by the bed or
chair.
Bony prominence points, such as
sacrum, elbows, heels, outer
ankles, inner knees, hips,
shoulder blades, and occipitae
bone.

Friction and shearing

Friction is a force acting parallel create
friction. For example, sheets rubbing against
skin create friction.
Shearing force is a combination of friction
and pressure.
It occurs commonly when patient in Fowlers
position.
When body tends to slide downward; this
downward movement apply friction and
pressure on sacral bone and deep tissues.

Immobility
- Reduction in movement of a person increase
risk for pressure ulcer development.
- For instance, patient with paralysis, extreme
weakness, pain, or any cause of decreased
activity.
Inadequate nutrition
- This causing weight loss, muscle atrophy, and
loss of subcutaneous tissue.
- Subsequently, reduce the amount of padding
between the skin and the bones, thus
increase the risk of pressure ulcer formation.

Fecal and urinary incontinence

- Moisture from the fecal and urine promotes
skin maceration and make the epidermis
more easily eroded and susceptible to injury.
- The incontinence of fecal and urine also
cause excoriation, risk of infection.
Decreased mental status
- Individual with reduce level of consciousness,
for instance unconscious patient, heavily
sedated patient are at high risk of pressure
ulcer development due to reduction in pain
sensation.

Excessive body heat

Elevated of body temperature increase the
metabolic rate, thus increase the cells need
for oxygen.
These increase particular severe in pressure
areas, which already compromised in oxygen
supply.
Advanced age
Aging cause older person more prone to
impair skin integrity.
For instance, decrease strength and
elasticity of skin, loss of muscle tone,
increase skin dryness, decrease blood flow
and so on.

Chronic medical conditions

- Such as diabetes and cardiovascular disease
are risk factors for skin breakdown and
delayed healing.
Others factors
- Such as poor lifting and transferring
techniques, incorrect positioning, hard
support surfaces, and incorrect application
of pressure devices.

The tough, supple cutaneous membrane that

covers the entire surface of the body.
Composed of a thick layer of connective
tissue called dermis and epidermis.

Stages 1
- Nonblanchable erythema
signaling potential
ulceration.

Stage 2
- Partial-thickness skin loss
(abrasion, or blister)
involving the epidermis and
possibly dermis.

Stage 3
- Full-thickness skin loss
involving damage or necrosis
of subcutaneous tissue that
may extend down to, but not
through, underlying fascia.

Stage 4
- full-thickness skin loss with
tissue necrosis or damage to
muscle, bone, or supporting
structures, such as a tendon
or joint capsule.
Undermining and sinus tracts
may also present.

Redness, tenderness , and discomfort.

The area becomes cold to touch and
insensitive.
Local edema, then becomes blue, purple or
mottled.
Due to continued pressure, the circulation is
cut off, the gangrene develops and the
affected area is sloughed off.

Management and prevention of pressure

ulcers begin on hospital admission, especially
over bony prominences.
Steps to prevent pressure ulcers:

Ensure skin is clean, and prevent it from

getting too dry by using moisturizing lotions.
Provide balanced diet high in protein,
vitamins, and mineral for tissue repair.
Ensure a fluid intake of 2000 ml/day for
adequate hydration.

Place patient on pressure-reducing mattress

or chair cushion.

Use turning sheet to reposition.

Positioning is the basic standard of ulcer
prevention.
Reposition a bedridden patient at least every
2 hours; reposition a chair-bound patient
every hour.
Complete a risk assessment
for patient, evaluating
factors for developing
pressure ulcers.

Daily skin assessment on high-risk patient for

sign of pressure ulcer.
Ensure smooth, firm and wrinkle-free bed for
patient.
Donut rings should not be used to relieve
pressure because they reduced blood supply.

A management and prevention of pressure

ulcers.
Purposes:
To clean and massage all pressure areas.
To prevent skin breakdown from pressure
points.
To stimulates blood circulation.
To promote relaxation and relieve muscle
tension.

Switch of fan or air-condition to prevent

patient getting chill during procedure.
Place patient on lateral/ semi-prone/ prone
position.
Apply lotion/massage oil on the palm, then
apply on the patients back.
The palms should remain in constant skin
contact with patients back until backrub is
complete.

Lubricate patients back with broad

circulating movements.
Start from sacrum to neck, massage back of
neck and shoulders using firm circular
movements.
Follow the sequent for each steps:
lubricating stroking, petissage, digital
kneading, wringing, digital friction,
percussion-chopping, percussion-beating,
percussion-tapotement.
Assess patient throughout the procedure.

Comfort the patient.

Report and record any abnormality.