halime aydın, bengüsu Öroğlu, gülcan kar, mustafa Öncel pressure wound md. lÜtfİ kirdar...
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Halime Aydın, Bengüsu Öroğlu, Gülcan Kar, Mustafa Öncel
PRESSURE WOUND
MD. LÜTFİ KIRDAR KARTAL EDUCATION AND RESEARCH
HOSPITALSTOMATOTHERAPY UNIT
PRESSURE WOUND
Pressure wound is lokalized tissue damage that usually occurs skin on bones and subcutaneous tissues via pressure or friction and rupture with pressure.
(NPUAP, 2007)
The most cheapest and easy way to prevent pressure wound is applications of
preventer nurse procedures.
However wounds with different grades occur because of various reasons.
It is aimed that quick recovery with good nursing and wound care.
PRESSURE WOUND
Patiens having pressure wounds are usually older than 70 age and have 8% mortality risk. (Oguz,1998)
Risk factors that induce pressure wonds without old age;Neurological diseases, Malnutrition,Chronic diseases, Physical inactivity.
CASECASE
Woman H.A., 85 age, mother of 5 children.
Blind for 40 years.
Urinar and fecal incontinence for 2-3 years.
She was hospitalized for general stiuation disorder at 29 September 2009.
It was observed that she had not any chronic disease as a result of investigations (hypertension, diabetes etc.).
HOWEVER….HOWEVER…. It was confirm that extreme malnutrition.
It was found that pressure wounds more than one.
(Sacral, torachanter and heel area)
EVALUATION RISK OF PRESSURE WOUND FORMING WITH BRADEN SCALE
EMOTIONAL SENSE
1-COMPLETELY LIMITED
2-MOSTLY LIMITED 3-SLIGHTLY LIMITED
4-NO DAMAGE
MOISTURE/WET 1-ALWAYS WET 2-FREQUENTLY WET 3-SOMETIMES WET
4-RARELY WET
ACTIVITY 1-LIVE BEDRIDDEN 2-SIT CHAIR 3-SOMETIMES WALK
4-WALK
MOTION 1-COMPLETELY INACTIVE
2-VERY LIMITED 3-SLIGHTLY LIMITED
4-NO LIMITED (ACTIVE)
NUTRITION 1-UNSUFFICIENT (CACHECTIC)
2- PARTIALLY ENOUGH
3-ENOUGH 4-VERY GOOD
FRICTION AND RUPTURE
1-PROBLEM 2- MAY BE PROBLEM 3- NO PROBLEM
*19–23: NO RİSK *15–18: RISK ON THE EDGE *13–14: MEDIUM RISK *0–12:HIGH RISK *9 AND LOWER: VERY HIGH RISK
*RISK OF PRESSURE WOUND FORMING IS 15–18 AND LOWER LOOK AT THE GUIDE OF NURSING PLAN FOR DAILY ACTIVITIES.
PUAN
TOPLA
CASE
SACRAL AREA
PHASE III VE PHASE IV
SACRAL AREA: 22x15x5 cm
29Eylül200929Eylül2009
Torachanter 10x7x7 cm
Suspicious subcutaneous lesion
HEELSuspicion of deep tissue damage
HELL 5X5 CM PHASE II-III
NURSING PLAN
Change position of patient to reduce pressure every 2 hours,
Provide using of support materials to reduce pressure,
Clean and dry skin, Clean and creaseless sheet, Organize nurition and fluid intake, Provide adaptation of patient’s relative to nursing
plan via training.
It was gave that suitable position to the patient and changed every 2 hours.
It was provided that enough fluid intake and organized nutrition (eternal nutrition).
Skin care was done. The family was trained
for this subjects.
NURSING
Healty tissue around
the wound was cleaned with batticon.
İnternal wound was washed with normal saline.
Necrotic tissues were removed with surgical debridement.SACRAL AREA: 22x15x5 cm
WOUND CARE STEP BY STEP
AFTER 2 WEEKS 20x14x5
Infected, smelly internal wound was washed with normal saline and silver wound dressing was applied.Cavity spaces were filled with this silver woud dressing. Barrier cream was used to protect wound around.The area with rich exudate was covered with NEODERM® .
AŞAMA AŞAMA YARA BAKIMI
AFTER 6 MONTHS 13X7X2 cm
AFTER 4 MONTHS 8X4X0.5 30.01.2010
Wound was cleaned completely and there was no necrotic area.This stage, Neoderm® was applied again.
FIRST LATER
Skin was cleaned and 80-100 mL, infected, smelly and sludgy exudate was drained via opening necrotic area with surgical incision. Internal wound was washed with isotonic solution for several times and wound space was filled with silver wound dressing.
AŞAMA AŞAMA YARA BAKIMI
TORACHANTER AREASUSPICION OF DEEP TISSUE
DAMAGE
TORACHANTER AREA
Barrier cream was applied to around tissues.
Wound area with rich exudate was covered with Neoderm®.
At first, dressing was done day to day. After that, changing time was extended because of decreasing exudate.
30.9.2010 OPEN WOUND
AŞAMA AŞAMA YARA BAKIMI
AFTER OPENING TORACHANTER AREA 10x7x7 cm
AFTER 6 WEEKS
AFTER 8 WEEKS 6X4x3 cm
AFTER 4 MONTHS 3X3X3cm
AFTER 5 MONTHS 1X1.5X0.5 cm
FIRST LATER
HEEL 5X5 cm
AFTER 6 WEEKS
AFTER 4 MONTHSAFTER 2 MONTHS
NEODERM® APPLICATION
AFTER 5 MONTHS 2X2X1cm
FIRST LATER
RESULT
Pressure wounds can be treated applying well organized nursing,
And doing effective and organized wound care.
WITH HER GRANDCHILD CANSU
THANK YOU