Pressure ulcer assessment and management
•Download as PPTX, PDF•
93 likes•66,511 views
Wound care www.woundcarenurses.org
![Pressure Ulcer Assessment and Management OBJECTIVES By the end of the course participants will be able to: ,[object Object], non-pressure etiology. ,[object Object], pressure ulcer management.](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
Recommended
Recommended
More Related Content
What's hot
What's hot (20)
Similar to Pressure ulcer assessment and management
Similar to Pressure ulcer assessment and management (20)
Recently uploaded
Recently uploaded (20)
Pressure ulcer assessment and management
- 1. Pressure Ulcers Assessment and Management By Alex Khan RN BSN CWCN CFCN www.woundcarenurses.org DEVELOPED FOR
- 4. Dermis
- 5. Subcutaneous tissueThough interrelated, each layer of skin has different structures, cell types and functions.
- 6. What are Pressure Ulcers? Localized areas of tissue necrosis which develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time. Most pressure ulcers occur over bony prominences, where combined with friction and shearing forces result in skin breakdown. Several factors other than pressure contribute to ulcers including moisture, friction, shear, immobility, sensory loss and some underlying medical conditions.
- 7. Common Pressure Ulcers sites Supine: 23% sacro-coccygeal 8% heels 1% occiput; spine Sitting: 24% ischium 3% elbows Lateral: 15% trochanter 7% malleolus 6% knee 3% heels
- 9. STAGE II
- 10. STAGE III
- 11. STAGE IV
- 12. SUSPECTED DEEP TISSUE INJURY (DTI)
- 20. Use Foam or Calcium Alginate dressing for moderate to copious drainage management.
- 24. Use Foam or Calcium Alginate dressing for moderate to copious drainage management.
- 25. Slough 30% or less in the wound, negative pressure wound therapy is preferred treatment.
- 28. Off load area of pressure ulcer with pressure relieving / distribution surface and turning and repositioning schedule.
- 29. Use Foam dressing for drainage management.
- 32. Off load area of pressure ulcer with pressure relieving / distribution surface and turning and repositioning schedule.
- 33. Use Foam dressing for drainage management.
- 34. Castor oil / Balsam / Peru / Trypsin spray is the preferred treatment for wounds with Intact eschar.
- 36. Bowel & Bladder Incontinence
- 37. Shearing and friction injuries
- 38. Advanced age
- 39. Malnutrition or debility
- 40. Obesity
- 41. History of pressure ulcers
- 42. Dehydration
- 43. Contractures
- 44. Use of orthotic devises or restraints
- 45. Lack of compliance
- 47. Maximal Remobilization: Passive range of motion, physical therapist (PT) consult to plan appropriate measures for patient. Spinal Cord Injury and Disorder (SCI&D) patients (or any patient with custom chairs) are to sit in their own wheelchairs and cushions only.
- 48. Protect Heels: Support entire leg with pillows to allow heels to suspend above the mattress or use heel protectors. Assess heels everyday for signs of pressure. Consider pressure relieving / distribution bed surface.
- 49. Manage Moisture: Correct cause, (e.g., diarrhea), reduce or eliminate incontinent episodes (e.g., bladder training); Use mild soap, rinse, and dry skin well and apply moisture barrier cream. No diapers while patient in bed.
- 50. Manage Nutrition: Increase protein intake more than 100% RDA, if not renal or liver impaired. Dietary consult to determine dietary needs and/or effectiveness of tube feedings.