Chapter 5 Assisting Clients With Hygiene

Section 6 Prevention and Care of Pressure Ulcers

contents

Contributing Factors to Pressure Ulcers Formation

Prediction and Prevention of Pressure Ulcers

Treating and nursing pressure ulcer

Economic consequences of pressure ulcers

Frequency: 3-14%,2-25%(nursing home) 85.7% paraplegia 58% pressure ulcer ＞ 65y

Economic consequences: Days in hospital increase Cost of heath care increase: $4,000-40,000

decubitus ulcer, and bedsore

Concept: pressure sore,

a localized area of tissue lesion and necrosis that tends to develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period, blood circulation is obstructed, and local tissue is ischemic.

Pressure ulcer

Contributing Factors to Pressure

Ulcers Formation Factor of pressure

Pressure Friction Shearing force

Moisture irritation to the Skin Nutritional Status Age Fever (infection) Orthopedic Devices

垂直压力

剪切力

摩擦力

Pressure

Shearing

force

Friction

Factor of pressure

Moisture irritation to the Skin

urinary and fecal incontinence wound drainage sweat

Nutritional Status

Malnutrition Protein malnutrition Protein- energy malnutrition

Cachexia Obesity Dehydration Edema

Age

Gerontologic nursing practices for the client with impaired skin integrity

★Older adult’s skin is less tolerant to pressure, friction, and shearing force because of decreased elasticity due to normal aging.

★The older adult has decreased number of sweat glands, leaving the skin dry and less tolerant to shear and friction.

★Impaired skin integrity is a high risk to older adult; it is among the five most common nursing diagnoses for older adult clients in long-term care facilities.

★Dermis of the older adult’s skin is thinner due to the normal absence of subcutaneous fat, therefore making the older adult more susceptible to skin breakdown.

★After the age of 50 epidermal cell renewal reduces by one third, and as a result wound healing is approximately 50% slower than a 35-year-old adult.

★In the presence of chronic coronary or peripheral vascular diseases circulation to the extremities is reduced.

Fever (infection)

increase the body’s metabolic rate increasing the needs of the cells for oxygen Make hypoxemic tissue more susceptible to

ischemic injury diaphoresis

increased skin moisture irritation

Orthopedic Devices

plaster, bandage, splint, retractor reduce mobility of the client or of an

extremity friction pressure

Prediction and Prevention of Pressure

Ulcers Assessment

Patients With High Risk of Pressure Ulcers Predicting Pressure Ulcers Risk Common Pressure Ulcer Sites

Preventative interventions

Patients With High Risk of Pressure Ulcers!

Clients with the neural diseases Old people Obesity Debilitated and malnutrition Edema Pain orthopedic devices urinary and fecal incontinence fever quietive therapy

Predicting Pressure Ulcers Risk

predictive instruments the Braden Scale the Norton Scale the Gosnell and Knoll instruments

Items/points 4 3 2 1

Activity

 

Mobility

 

Friction and

shear

 Sensory perception

 

Moisture

 

Nutrition

Walks frequently

 No

limitations

Not at all

 

No impairment

 

Rarely moist

 

Excellent

Walks occasionally

Slightly limited 

No apparent

problem

Slightly limited

 Occasionally moist

Adequate

Chairfast

 

Very limited

 

Potential problem

Very limited

Very moist

 Probably inadequate

Bedfast

 

Completely immobile

Problem

Completely

limited

Constantly moist

Very poor

the Braden Scale

Items/points 4 3 2 1Mental condition

Nutrition condition

Mobility

Activity

Incontinence

Circulation 

 

Temperature 

Medications

Alert

Good

Full

Ambulatory

Absent

Capillary promptly

36.6-

37.2℃ 

Not

Apathetic

Fair

Slightly limited

Walks with help

Urine incontinence

Capillary slowly

37.2-37.7℃ Administering sedatives

Confused

Poor

Very limited

Chair-bound

Fecal incontinence

Edema slightly

37.7-38.3℃ steroidal drugs

Stupor

Very poor

Immobile

Bedfast

Double

 

E moderate or serious

＞ 38.3℃ 

Double use

the Norton Scale

Common Pressure Ulcer Sites

bony prominences

1965 年 Indan等通过研究报告了人在坐和卧位时压迫点的分布，仰卧时，枕骨粗隆、骶尾部、足跟是压迫最重的部位，压力范围 5.3～ 8.0kPa(40 ～

60mmHg) 。

俯卧时膝部和胸部受到的压力接近 6.7kPa(50mmHg)

坐位时 ,集中到坐骨结节的压力高达10kPa(75mmHg) 。

supine position

枕部肩胛部肘部

骶尾部足

跟部Occipital

scapula

elbow

sacrum

heel

脊椎

spine carina

耳部肩峰肘部髋部踝部 内髁与外 髁

Lateral position

earshoulder

elbow

anterior iliac crest

medial,lateral knee

Medial, lateral malleolus

Prone position

肩峰足趾 膝部

面颊和耳 廓 乳房

（女性）

生殖器（男性）

cheek (ear)

shoulder Breast

(female)

breast(female) breast(female)

Genitals(male)

genitals(male)

knee

iliac crest, knee

toes

iliac crest

Sitting position

ischium tuber

shoulder

elbow

sole

sacrum

Preventative interventions

Preventative interventions

Avoid pressure on local tissues for prolonged period

Reduce shear and friction Protect skin of patients (Hygiene and

skin care) Stimulating blood circulation of skin Provide adequate nutrition Health education

Avoid pressure on local tissues for prolonged period

Turn the patients periodically (every 2 hours or 30 minutes necessarily)

Protect bony prominence and support interspace

Use the devices right, such as plaster, bandage, splint, retractor     

Avoid pressure on local tissues in prolonged period

Turn the patients periodically Protect bony prominence and

support interspace Use the devices right

翻身

支被架

气垫床褥

Devices used to prevent or treat pressure ulcers

Devices to support pressure areasFlotation pads are pliable pads with a consistency like

body fat, which disperse pressure over a larger area. Pillows and bridging techniques lift the pressure site off the mattress and separate two points of pressure.

Devices to aid in turning a clientA Guttman bed rotates the client from prone to supine

positions and from side to side.Kinetic therapy continuously rotates the client 270

degrees every 3 minutes.

Devices to minimize or equalize pressureAlternating air mattresses made of polyvinyl air cells

are attached to a pump that inflates and deflates them every 3-7 seconds, alternating pressure points.

Water mattresses disperse and evenly distribute the client’s body weight.

High and low air loss bed allow deformation of bed surface to the body contours, thereby reducing tissue pressure below capillary closure. These beds also eliminate shear and friction and reduce moisture.

Reduce shear and friction

For bedridden clients, elevated the head of the bed to no more than 30 degrees.

clients must be positioned, transferred, and turned correctly. lifting rather than dragging

bedpan

Protect skin of patients

keep the client’s skin and bedsheet clean and dry Clean,not soap ; daub ointments, Urine, stool, wound drainage;Vaseline or

zinc oxide Incontinence; diaper

Stimulating blood circulation of skin

range-of-motion,ROM Warm water bath in bed: see disc Check and massage skin

Local tissue massage back rub: see disc

Provide adequate nutrition

receive sufficient protein, vitamins (A, C, B1, B 5), and zinc

Health education

Educate clients and care givers regarding pressure ulcer prevention

Treating and nursing pressure ulcer

Stages of Pressure Ulcer

Stage I :nonblanchable erythema of intact skin, the heralding lesion of skin ulceration

Stage :Ⅱ Partial thickness skin loss involves damage or necrosis of epidermis, dermis, or both

Stage :Ⅲ Full thickness skin loss involves damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia

Stage :Ⅳ Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structure such as tendon or joint capsule

瘀血红润期（ hyperemia, nonblanchable erythema ）

heralding lesion.

temporary

circulation lesion

Manifestation: Redness(lightly skin) Red blue,purple hues

(darker skin) Redness, swollenness,

heat, and pain

炎性浸润期(ischemic,inflamation )

epidermis, dermis, or both

Gore,ischemic,

readness and swollenness

enlarged ； color: purple,

not change with pressed ；

superficial abrasion, blister

or shallow crater

浅度溃疡期 (superficial ulceration)

subcutaneous

tissue(superfi

cial tissue)

Blister is torn,

infection,

ichor,necrosis

and ulcer

坏死溃疡期 (Necrotic ulceration) Deep dermis,

muscle, bone,

tendon or joint

capsule

Necrosis turn blue,

ichor,

septicopyaemia

Treating pressure ulcer Supportive or systemic measures ：

providing adequate nutrition Protein status Hemoglobin

Controlling infection ： Body substance isolation and good hand

washing technique

Local care of the wound

Local care of the wound

Stage I Principle: eliminating risk factors or contributing factors to

pressure ulcers increasing turning frequency, avoiding local tissue pressed long

term, improving circulation, keeping bed linen clean, smooth, dry without oddment, reducing friction and shearing force, avoiding excretion and moisture stimulating to skin, increasing nutrition and enhancing immunity and so on.

Moist dressing Toast light Ban massage

Stage Ⅱ

Principle:protecting skin and preventing infection preventive measure followed intensify care of blister

Small untorn blister: big blister: see disc

draw out liquid in blister with sterile injector , unnecessarily scissoring pellicle, and then sterilize the surface and cover it with sterile dressings.

ultraviolet or infrared treatment.

Stage Ⅲ

Principle: keeping cleanliness of the ulcer area Eliminate pressure,keep clean physical therapy: Goosenecked light

Moisture-retentive dressings transparent films, hydrocolloid dressing, and

hydrogels新鲜的鸡蛋内膜、纤维蛋白膜、骨胶原膜等贴于创面

Stage Ⅳ

Principle: keeping cleanliness of the ulcer area, debriding necrotic tissue, keeping drainage smoothly, promoting acestoma growing

Stage Ⅳ Preventive measures Clean and rinse ulcer area: see disc

with sterilized normal saline or 1:5000 Furacilin solution, then covered with sterilized Vaseline gauze or dressings. Metronidazole dressing or be daubed with Sulfapyridine Argentums or Furacilin.

cleansed with 3% Hydrogen Peroxide solution for deep ulcer. keeping drainage smoothly oxygen therapy Surgery: debride necrotic tissue, skin grafting and

skin flap Chinese traditional medicine

Key term

Pressure ulcer, pressure sore, decubitus ulcer, and bedsore

Contributing Factors to Pressure Ulcers Formation

Pressure Friction Shearing force Moisture incontinence

Malnutrition obesity Cachexia Dehydration Edema hypoxemic ischemic Orthopedic Devices

plaster, bandage, splint, retractor hypoalbuminemia Mobility Activity Apathetic Bedfast Occipital bone, scapula, spine carina, elbow,

iliac crest, sacrum, heel

ear, shoulder, elbow, anterior iliac crest, trochanter, medial knee, lateral knee, medial malleolus, lateral malleolus

cheek (chin), ear, shoulder, breast(female), genitals(male), iliac crest, knee, toes

ischium tuber, shoulder, elbow, sacrum, sole bony prominence

nonblanchable erythema Partial thickness skin loss Full thickness skin loss Full thickness skin loss with extensive

destruction, tissue necrosis or damage to muscle,

septicopyemia, blister transparent films, hydrocolloid dressing, and

hydrogels debride Sulfapyridine Argentums eschar and slough skin grafting

Objectives

Concept of pressure ulcer Contributing Factors to Pressure Ulcers

Formation Patients With High Risk of Pressure

Ulcers Predicting Pressure Ulcers Risk Common Pressure Ulcer Sites

Preventative interventions Stages of Pressure Ulcer and its

manifestation Treating pressure ulcer

谢谢 !谢谢 !