pressure sore 23426

PRESSURE SORES (BEd

SORES)

Presented by: Ms.CELINE ANTONY

What are Pressure Ulcers?An area of localised damage to the

skin and underlying tissue caused by pressure, shear, friction and/or a combination of these

European Pressure Ulcer Advisory Panel EPUAP (2003)

Area of skin breaks down when no movement occursCommonly referred to as bed sores, pressure damage, pressure injuries and decubitus ulcers........

Pressure Ulcer Risk Factors• Internal/patient-related

factors:• Systemic disease: metabolic,

neurological, vascular, terminal i l lness

• Reduced mobil ity or immobility • Sensory impairment• Psychological e.g. depression

• Anaemia • Malnutrit ion• Level of consciousness• Extremes of age• Previous history of pressure

damage or poor skin condition• Acute or chronic oedema• Dehydration/fluid status- sweat,

incontinence

External factors:Pressure - support surfaces,

change of positionShear - positioning, mobil ityFrict ion - moving and handling

techniques, patient education, splinting, casts, positioning

Other factors- Moisture - incontinence,

sweating, pyrexia, wound exudates

- Medication

Age: Older patients may have poor circulation- less O2 to the tissue

Lack of Mobility: Pressure ulcers form when a patient is left in one position

in bed for too long.

Poor Appetite: Pts who are dehydrated or have a poor appetite are at risk for pressure ulcers.Unwanted Moisture: Patients that are incontinent of urine or stool or those who sweat are at risk for a pressure ulcer

Pressure Ulcers in the PastPatients who have had a pressure ulcer in the past are at greater RISK of getting another one.

Who’s at Risk?Bedridden/wheelchair boundFragile skin/Older ageChronic disease that prevents blood flowSpinal Cord Injury/Brain InjuryAlzheimer’s Disease

Pressure Points on the human body:

Supine position (lying on back)

Prone position (lying on stomach)

Lateral postion (lying on side)

Sitting position

Pressure Ulcer StagingStage I

Epidermis; nonblanching erythema

Dark Skin

Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.

Stage II

Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue/ fascia

Stage III

Full thickness skin loss with extensive destruction, t issue necrosis, or damage to fascia + bone, tendon, muscle, carti lage.

• The National Pressure Ulcer Advisory Panel has redefined the definition of a pressure ulcer and the stages of pressure ulcers

• Suspected DTI• Stage I• Stage II• Stage III• Stage IV• Unstageable

Suspected deep tissue injury Purple or maroon localized area of

discolored intact skin or blood-filled blister due to damage of underlying soft from pressure and/or shear. Unstageable

• Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the ulcer bed. from pressure and/or shear*.

EffEctivE managEmEnt of a prEssurE ulcEr

The Braden Scale

Braden Scale Norton Scale

Activity Mobility Incontinence Sensory Perception

Moisture

Friction & Shear

Nutrition

Physical Condition Mental Condition

Methods Used To PreventPressure Ulcers

Identify areas where pressure ulcers most frequently occur.Keep skin clean and dryReposition residents at least every two hoursKeep linen dry and free of wrinkles and objects that cause pressure to the skinClean urine and feces from skin as soon as possible

Make sure clothing and shoes do not bind or constrictPat skin dry when bathing; never scrubEncourage adequate nutrition and fluids

Massage pressure points when the resident is repositionedReport any changes in skin condition immediately

PillowsPillows

Water bedsWater beds

Bed cradle Bed cradle elbow protectorselbow protectors

Flotation padsFlotation pads

pressure mattresspressure mattress

Preventive Devices

TreatmentRelieve pressure in area (pillows, cushions)Physician can treat depending on stageAvoid further traumaPrevent infection by properly cleaning open ulcersMedication to promote skin healing

Calcium alginates or other fiber gelling dressings: Absorbs drainage and turns to a gel to maintain a moist wound bed Impregnated gauze: Used for packing, can deliver antimicrobial, medications and moisture, for partial or full-thickness wounds.Hydrocolloid: Contains gel-forming agents

Antimicrobials: Controls or decreases bioburden (e.g., silver dressings, hydrofera blue, cadezomer iodine, honey)Debridement is the removal of necrotic tissue or contaminated foreign matter.

DO NOT…Massage the area

Damage tissue under the skin

Use donut-shaped or ring-shaped cushions

Interfere with blood flow

Documentation of assessment, plan of action and re-assessment is your

only proof of good care.

If it is not written down ,

it never happened!

European Pressure Ulcer Advisory Panel

Thank you for your Time & aTTenTion!