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PRESSURE
ULCERS
By
Mr. M. Shivanandha Reddy
Bed Sores
DEFINITION:
• A Pressure Ulcer or Pressure Sore or
Decubitus Ulcer or Bedsore is localized
injury to the skin an...
Risk Factors
1. Friction
2. Shear
3. Impaired Sensory Perception
4. Impaired Physical Mobility
5. Altered Level Of Conscio...
Risk Factors
7. Malnutrition
8. Dehydration
9. Excessive Body Heat
10.Advanced Age
11.Chronic Medical Conditions- Diabetes...
Pathophysiology
Pressure sore
Ischemic necrosis
Reduced tissue perfusion
Occlusion & tearing of small blood vessels
When t...
Common Sites
Stages / Classification Of Bedsores
• Staging systems for pressure ulcers are
based on the depth of tissue destroyed.
• Ba...
Stage I: Nonblanchable Redness
of Intact Skin
• Intact skin presents with nonblanchable
erythema of a localized area usual...
Stages / Classification Of Bedsores
Stages / Classification Of Bedsores
Stage II: Partial-thickness
Skin Loss Or Blister.
• A partial thickness loss of dermis presents
as a shallow open ulcer wi...
STAGE II PRESSURE ULCER
STAGE II PRESSURE ULCER
Stage III: Full-thickness Skin
Loss (Fat Visible).
• A stage III ulcer is a full-thickness tissue
loss. Subcutaneous fat m...
STAGE III
STAGE III
Stage IV: Full-thickness Tissue
Loss
• A stage IV ulcer is is the deepest,
extending into the muscle, tendon or
even bone....
Stage IV
Stage IV
Complications
• Cellulitis
• Bone and joint infections
• Sepsis
• Cancer
Prevention
• Bedsores are easier to prevent than to
treat. Although wounds can develop in
spite of the most scrupulous car...
Prevention
1. Position changes
Changing position frequently and consistently is
crucial to preventing bedsores. Experts ad...
Prevention
3. Nutrition
A healthy diet is important in preventing skin
breakdown and in aiding wound healing
Adequate hydr...
Treatment
• 1. Changing positions often. Carefully follow
the schedule for turning and repositioning —
approximately every...
Treatment
Treatment
• 3. Cleaning. It's essential to keep wounds
clean to prevent infection. A stage I
wound can be gently washed wi...
Treatment
• 5. Removal of damaged tissue (debridement).
To heal properly, wounds need to be free of
damaged, dead or infec...
Treatment
• Surgical repair
• Tissue flap.
• Plastic surgery may be required to replace the
tissue.
• Other treatment opti...
Role Of Nurse In Prevention &
Management Of Bed Sores
• The nurse should be continuingly assessing the
client who are at r...
ROLE OF NURSE…..
Inspect for dry skin, moist skin, breaks in skin
Evaluate level of mobility.
 Evaluate circulatory sta...
ROLE OF NURSE…..
Interventions for a patient with Decreased sensory
perception
• Assess pressure points for signs of bed s...
ROLE OF NURSE…..
Interventions to avoid Friction and shear
• Reposition patient using draw sheet and lifting
off surface.
...
ROLE OF NURSE…..
Interventions for a patient with Decreased
activity/ mobility
• Establish individualized turning schedule...
ROLE OF NURSE…..
• Evaluate the ulcer progress every 4-6 days.
• Assist the physician or surgeon in debridement
• Educate ...
Bed sores / decubitis ulcer / pressure sores
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Bed sores / decubitis ulcer / pressure sores

this topic is on bed sores. discusses the definition, etiology , pathophysiology of bed sore development as well as prevention and managemene of pressure sores

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Bed sores / decubitis ulcer / pressure sores

  1. 1. PRESSURE ULCERS By Mr. M. Shivanandha Reddy
  2. 2. Bed Sores DEFINITION: • A Pressure Ulcer or Pressure Sore or Decubitus Ulcer or Bedsore is localized injury to the skin and other underlying tissue, usually over a body prominence, as a result of prolonged unrelieved pressure.
  3. 3. Risk Factors 1. Friction 2. Shear 3. Impaired Sensory Perception 4. Impaired Physical Mobility 5. Altered Level Of Consciousness 6. Fecal And Urinary Incontinence
  4. 4. Risk Factors 7. Malnutrition 8. Dehydration 9. Excessive Body Heat 10.Advanced Age 11.Chronic Medical Conditions- Diabetes, Cardiovascular Diseases.
  5. 5. Pathophysiology Pressure sore Ischemic necrosis Reduced tissue perfusion Occlusion & tearing of small blood vessels When this pressure exceeds normal capillary pressure Various risk factors act on areas of soft tissue overlying bony prominence
  6. 6. Common Sites
  7. 7. Stages / Classification Of Bedsores • Staging systems for pressure ulcers are based on the depth of tissue destroyed. • Based on the depth there are four stages of bedsores 1. Stage I 2. Stage II 3. Stage III 4. Stage IV
  8. 8. Stage I: Nonblanchable Redness of Intact Skin • Intact skin presents with nonblanchable erythema of a localized area usually over a bony prominence. • Discoloration of the skin, warmth, edema or pain may also be present • Stage I indicates “at-risk” persons. • Involves only the epidermal layer of skin.
  9. 9. Stages / Classification Of Bedsores
  10. 10. Stages / Classification Of Bedsores
  11. 11. Stage II: Partial-thickness Skin Loss Or Blister. • A partial thickness loss of dermis presents as a shallow open ulcer with a red-pink wound bed without slough • Stage II is damage to the epidermis and the dermis. In this stage, the ulcer may be referred to as a blister or abrasion.
  12. 12. STAGE II PRESSURE ULCER
  13. 13. STAGE II PRESSURE ULCER
  14. 14. Stage III: Full-thickness Skin Loss (Fat Visible). • A stage III ulcer is a full-thickness tissue loss. Subcutaneous fat may be visible; but bone, tendon, or muscle is not exposed. • Epidermis, dermis and subcutaneous tissues involved • subcutaneous layer has a relatively poor blood supply. So its difficult to heal.
  15. 15. STAGE III
  16. 16. STAGE III
  17. 17. Stage IV: Full-thickness Tissue Loss • A stage IV ulcer is is the deepest, extending into the muscle, tendon or even bone. • Full thickness tissue loss with exposed bone, tendon or muscle.
  18. 18. Stage IV
  19. 19. Stage IV
  20. 20. Complications • Cellulitis • Bone and joint infections • Sepsis • Cancer
  21. 21. Prevention • Bedsores are easier to prevent than to treat. Although wounds can develop in spite of the most scrupulous care, it's possible to prevent them in many cases.
  22. 22. Prevention 1. Position changes Changing position frequently and consistently is crucial to preventing bedsores. Experts advise shifting position about every 15 minutes that you're in a wheelchair and at least once every two hours, even during the night, if you spend most of your time in bed. 2. Skin inspection Daily skin inspections for pressure sores are an integral part of prevention
  23. 23. Prevention 3. Nutrition A healthy diet is important in preventing skin breakdown and in aiding wound healing Adequate hydration to maintain the skin integrity. 4. Lifestyle changes – Quitting smoking Exercise - Daily exercise improves circulation 5. Use pressure-relieving devices such as air mattress, water mattress.
  24. 24. Treatment • 1. Changing positions often. Carefully follow the schedule for turning and repositioning — approximately every 15 minutes if in a wheelchair and at least once every two hours when in bed. If unable to change position on own, a family member or other caregiver must be able to help. • 2. Using support surfaces. These are special cushions, pads, mattresses and beds that relieve pressure on an existing sore and help protect vulnerable areas from further breakdown.
  25. 25. Treatment
  26. 26. Treatment • 3. Cleaning. It's essential to keep wounds clean to prevent infection. A stage I wound can be gently washed with water and mild soap, but open sores should be cleaned with a saltwater (saline) solution each time the dressing is changed. • 4. Controlling incontinence
  27. 27. Treatment • 5. Removal of damaged tissue (debridement). To heal properly, wounds need to be free of damaged, dead or infected tissue. • 6. Dressings. • 7. Oral antibiotics. • 8. Healthy diet. • 9. Educating the caregiver
  28. 28. Treatment • Surgical repair • Tissue flap. • Plastic surgery may be required to replace the tissue. • Other treatment options Researchers are searching for more effective bedsore treatments. Under investigation are hyperbaric oxygen and the topical use of human growth factors.
  29. 29. Role Of Nurse In Prevention & Management Of Bed Sores • The nurse should be continuingly assessing the client who are at risk for pressure ulcer development Assess the client for: The predisposing factors for bed sore Development.  Skin condition at least twice a day.  Inspect each pressure sites.  Palpate the skin for increased warmth.
  30. 30. ROLE OF NURSE….. Inspect for dry skin, moist skin, breaks in skin Evaluate level of mobility.  Evaluate circulatory status (eg. Peripheral pulses, edema).  Assess neurovascular status.  Determine presence of incontinence Evaluate nutritional and hydration status. Note present health problems.
  31. 31. ROLE OF NURSE….. Interventions for a patient with Decreased sensory perception • Assess pressure points for signs of bed sore development. • Provide pressure-redistribution surface. Interventions for a patient with incontinence • Assess need for incontinence management. • Following each incontinent episode, clean area and dry thoroughly. • Protect skin with moisture-barrier ointment.
  32. 32. ROLE OF NURSE….. Interventions to avoid Friction and shear • Reposition patient using draw sheet and lifting off surface. • Use proper positioning technique. • Avoid dragging the patient in bed • Use comfort devices appropriately.
  33. 33. ROLE OF NURSE….. Interventions for a patient with Decreased activity/ mobility • Establish individualized turning schedule. • Change position at least once in two hours and more frequently for the high risk individuals. Interventions for a patient with Poor nutrition • Provide adequate nutritional and fluid intake • Assist with intake as necessary. • Consult dietitian for nutritional evaluation
  34. 34. ROLE OF NURSE….. • Evaluate the ulcer progress every 4-6 days. • Assist the physician or surgeon in debridement • Educate the patient and family regarding the risk factors and prevention of bed sores.

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