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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
3.
4.
5.
6.
7.
8.
Transmitted to sacral bone & deep tissues
Shearing force in the area where deeper tissues & superficial meet
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
Tissue dies
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:
Stage IV
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.
Stage
1
Treatment goals
Protect the skin
and
remove the cause
II
III and IV
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
Surgical procedures
Pharmacological management