Pressure Ulcer

Care

Pressure - the continuous physical

force exerted on or against an object
by something in contact with it.

 Pressure ulcer- also called bed sores or

decubitus ulcer
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
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 that frequently act in

conjunction with pressure to produce
pressure ulcer

Friction
Force acting parallel to the skin surface
Can abrade skin removing the superficial
layers

 Shearing Force
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 of PRESSURE

ULCER
Immobility
Inadequate Nutrition
Fecal & Urinary Incontinence
Decreased Mental Status
Diminished Sensation
Excessive Body Heat
Advanced Age
Chronic Medical Conditions
Other factor

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)

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.

Nursing Interventions
GOAL: Protect the skin and remove the cause
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

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.

Nursing Intervention
Goal: Protect the skin and manage exudates; closure
and regrowth of skin
Manage exudates/moisture: Apply wound dressing;
change every 35 days 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

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.

Nursing interventions
Goal: Protect and keep wound clean; manage
exudates; and reduce wound size
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;

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.

Nursing interventions
Goal: Protect and keep wound clean; manage
exudates; and reduce wound size
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;

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.

Surgical management
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

 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.

 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

 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,

 Hydrocolloids / Hydrogels: Hydrocolloid dressings have

gel-like properties and absorb fluids from the wound.
Because hydrocolloid dressings form a moisture-proof
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

pressure ulcer care

Guidelines
Use inAseptic
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