Pressure Ulcer Prevention and Development PDF

What is pressure ulcer? A pressure ulcer is a sore that develops when part of a person’s body presses against a hard surface (such as a mattress or the seat of a chair) for a long period of time. It is usually developed over bony prominences such as the back of the head, shoulder blades, el...

What is pressure ulcer? A pressure ulcer is a sore that develops when part of a person’s body presses against a hard surface (such as a mattress or the seat of a chair) for a long period of time. It is usually developed over bony prominences such as the back of the head, shoulder blades, elbows, hips, coccyx (tailbone), knees, ankles and heels. How can pressure ulcer develop? Friction and shearing injuries can also lead to skin breakdown, putting a person at risk for developing a pressure ulcer. Friction is the rubbing of one surface against another. When moved in bed, the person's skin rubs against the sheet. Medical devices, such as catheter tubing or a nasal cannula, can also cause friction injuries when they rub against the skin. How can pressure ulcer develop? Shearing is when the skin sticks to a surface while muscles slide in the direction the body is moving. It occurs when the person slides down in bed or is moved in bed. How can pressure ulcer develop? To reduce friction and shearing when moving the person in bed: Roll the person. Use friction-reducing devices. Such devices include a lift sheet (turning sheet). Draw sheets serve as lift sheets (turning sheets). Turning pads, large re-usable waterproof under-pads, and slide sheets are other friction-reducing devices. Risk Factors for Pressure Ulcer Development Aging and age-related skin changes. Skin breakdown and non-intact skin. Dry skin. Fragile and weak capillaries. General thinning of the skin. Loss of the fa y layer under the skin. Decreased sensation to touch, heat, and cold. Decreased mobility. Risk Factors for Pressure Ulcer Development Limited activity: for example, sitting in a chair or lying in bed most or all of the day. Chronic diseases (diabetes, high blood pressure). Diseases that decrease circulation and oxygen to tissues; poor circulation to an area. Fever. Poor nutrition. Poor hydration. Risk Factors for Pressure Ulcer Development Incontinence: urinary, fecal. Moisture in dark body areas: skin folds, under breasts, perineal area. Pressure on bony parts (pressure points). Poor fingernail and toenail care. Friction (rubbing of 1 surface against another) and shearing. Edema (the swelling of body tissues with water). Pressure ulcer Pressure ulcers develop in stages and can be very difficult to treat, especially in the later stages. Pressure ulcers are extremely painful for the person, and they can lead to the person’s death. For these reasons, every effort must be made to prevent a pressure ulcer from forming in the first place. Prevent Pressure ulcer A nurse assistant will play a very important role in helping to keep the person’s skin healthy and prevent pressure ulcers. Closely observing the person’s skin for: Signs of excessive pressure and skin breakdown. Providing care. Reporting the observations to the nurse. Prevent Pressure ulcer Help to prevent a pressure ulcer in the early stages from getting worse. Help to prevent pressure ulcers by regularly helping the people in care to reposition themselves, if they cannot do this independently. ! Observations Into Action! A reddened or darkened area that does not return to normal within a few minutes when the pressure is relieved. A white, pale or shiny area. An area that feels hot or cool to the touch or is painful. Stages of Pressure Ulcer Development Stage 1 An area is red, pale or dark, and the normal color does not return within a few minutes of relieving the pressure. The area may be firmer, softer, warmer, cooler or more painful than the surrounding tissue. Detection may be more difficult in people with darker skin. Stages of Pressure Ulcer Development Stage 2 The area may look like a shallow, open ulcer with pink or red exposed tissue at the bottom. Sometimes, instead of looking like an ulcer, the area looks like a blister. Stages of Pressure Ulcer Development Stage 3 More tissue is lost. The fat that lies beneath the skin may be visible. Stages of Pressure Ulcer Development Stage 4 A deep crater forms. Muscle or bone may be visible. looks like a blister. Protecting the Person’s Skin To prevent Do this…. this…. Direct Change the person’s position according to the person’s care plan pressure and at least every 2 hours Observe and report immediately any reddened, pale or darkend and areas of the skin. Make sure the person is in good body alignment. use appropriate positioning aids when needed. Use pressure reducing devices such as pressure reducing mattress pads, heal, elbow protectors as order to relieve pressure and protect skin. If the person uses hair pins or barrettes to style the hair, make sure these items are removed when the person's head is resting on a pillow. Protecting the Person’s Skin To prevent this…. Do this…. Friction and Get help when moving the person—be sure to lift the person’s shearing body all the way off the mattress. injuries Elevate the head of the bed no more than 30 degrees (except when a person is eating or has difficulty breathing). This will keep the person from sliding down in bed. Avoid leaving the person in Fowler’s position for any length of time. Make a tight, neat, wrinkle-free bed. Prevent medical equipment from rubbing against the person’s body. Pad supportive devices (such as splints). Ensure that shoes and socks fit correctly. Protecting the Person’s Skin To prevent this…. Do this…. Skin-to-Skin Check for skin changes under skin folds, especially under Contact breasts, and under the folds of skin on people who are overweight. Position the person so that air circulates around the person’s arms and legs to keep skin from touching skin. Moisture Wash, rinse and dry the person’s skin thoroughly, especially in areas where skin meets skin. Check people with incontinence at least every 2 hours and keep their skin, clothing and linens clean and dry. Cover a vinyl chair with a pad or sheet. Have the person wear moisture-absorbing clothes made from natural fabrics such as cotton. Protecting the Person’s Skin To prevent Do this…. this…. Poor Elevate the person’s arms and legs. Circulation Provide gentle massage. Observe the person’s skin frequently and report any changes to the nurse. Nutrition Encourage the person to eat a well-balanced diet. and Encourage the person to drink an adequate amount of Hydration fluids. Mobility Reposition the person often. If the person is able, assist the person with transferring out of bed and walking.