PRESSURE SORE ASSESSMENT.pptx

PRESSURE SORE ASSESSMENT RESULTS ON STAYING A POSITION FOR A LONG PERIOD OF TIME WHICH RESULTS TO SORE

1. PRESSURE SORE ASSESSMENT PRESENTED BY: DIBIAGWU J.C ADRIAN ROLL NO: VU21NURS0100008 EVALUATED BY: ASHAPURNA MADAM

2. CONTENT 01 INTRODUCTION DEFINITION 02 RISK FACTORS STAGES OF PRESSURE SORES 03 COMMON AREAS AFFECTED NURSING INTERVENTIONS CONCLUSION.

3. INTRODUCTION Pressure sores can be defined as an injury to the skin and underlying tissues resulting from prolonged pressure on the skin which is mostly generated from lying or sitting down in one position for a very long period of time. Pressure sores are also known as bed sores or pressure ulcer.

4. DEFINITION . . Pressure sores can be defined as the breakdown of skin integrity and underlying tissues which occurs as a result of unrelieved pressure on the skin and is mostly generated from lying or sitting down in the same position for a very long period of time. Pressure sores are also known as bed sores , pressure ulcers , pressure injuries or decubitus ulcers .

5. RISK FACTORS .

6. RISK FACTORS POOR NUTRITION . IMMOBILITY NEUROLOGICAL ISSUES INCONTINENCE DIABETIC PATIIENTS CONSIDERING PATIENTS SUBJECTED TO THE FOLLOWING CONDITIONS :

7. STAGES OF PRESSURE SORE’S . .

8. 4 STAGES

9. STAGE 1:

10. . STAGE 1:

11. . STAGE 2:

12. . STAGE 2:

13. STAGE 3:

14. . STAGE 3:

15. STAGE 4:

16. STAGE 4:

17. COMMON AREAS AFFECTED BY PRESSURE SORES

18. COMMON AREAS HEELS & KNEES PRESENTATION

19. COMMON AREAS SHOULDERS & ELBOWS PRESENTATION

20. COMMON AREAS OCCIPITAL & EAR REGION PRESENTATION

21. NURSING INTERVENTIONS .

22. NURSING INTERVENTIONS 01 PREVENTION 02 DETECTION 03 WOUND CARE

23. 01 PREVENTION: PERFORM HEAD TO TOE ASSESSMENT. CONCENTRATE ON PATIENTS SKIN INTERGRITY. IF PRESSURE SORE IS OBSERVED, NURSES SHOULD DOCUMENT DETAILS OF THE PRESSURE SORE SUCH AS : SIZE, COLOR & DRAINAGE. NURSES SHOULD NOTIFY THE PHYSICIAN IMMEDIATELY IF THE PRESSURE SORE IS EXTREMELY SEVERE.

24. 01 PREVENTION: NURSING CARE PLAN : KEEPING PATIENTS SKIN CLEAN AND DRY. USE BARRIER CREAMS FOR PATIENTS WHO GENERATES SWEAT EASILY. NURSES SHOULD PUT ON ONLY CLEAN, DRY AND WRINKLE FREE LINEN FOR PATIENTS. CHANGE PATIENTS POSITION AFTER EVERY 2 HOURS.

25. 02 DETECTION: UPON EVERY SHIFT, NURSES SHOULD ASSESS THE PATIENTS RISK FACTORS FOR POTENTIAL PRESSURE INJURIES . NURSES SHOULD MAKE USE OF A BRADEN SCALE FOR THE ASSESSMENT, AND THE SCALE MUST CONTAIN THE FOLLOWING CATEGORIES: SENSORY MOISTURE ACTIVITY MOBILITY NUTRITION FRICTION & SHEAR

26. 02 DETECTION: ≤ 9------VERY HIGH RISK 19-23------VERY LOW RISK

27. 03 WOUND CARE: WOUND VACS . DEBRIMENT. SPECIAL DRESSING TO PROMOTE WOUND HEALING . HYPERBARIC OXYGEN THERAPY.

28. CONCLUSION: NURSES SHOULD NOT DELAY IN ADMINISTERING CARE TO PATIENTS WITH PRESSURE SORES. THE TREATMENT PATTERN FOR PRESSURE SORES COMPLETELY DEPENDS ON THE ANATOMICAL STAGE OF THE PRESSURE SORE. SPECIAL DRESSING TO PROMOTE WOUND HEALING . HYPERBARIC OXYGEN THERAPY.

29. THANK YOU !