Pressure sores prevention & Risk assessment.pptx

Med surg

1. PRESSURE SORE PREVENTION & RISK ASSESSMENT 1

2. Pressure sore also called as Decubiti ulcer or pressure ulcer or b edsores most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone. People most at risk of bedsores are those with a medical condition that limits their ability to change positions, requires them to use a wheelchair or confines them to a bed for a long time PRESSURE SORE-INTRODUCTION 2

3. Pressure sore is a localized area of tissue necrosis (death) that tends to develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period. “ Potter and Perry (2006 )” Chronically ill patients and debilitated people have a common risk for having poor hygiene, skin irritation and thus resulting in bedsores —they are injuries to skin and underlying tissue resulting from prolonged pressure on the skin. PRESSURE SORE-DEFINITION 3

4. Impaired sensory input: Patients with altered sensory perception for pain and pressure e.g. paralyzed patients, unconscious patients, etc Impaired motor function: Patients who are unable to change positions and relieve positions independently e.g. patients with spinal cord injuries RISK FACTORS 4

5. Alteration in level of consciousness: Patients who are confused, disoriented or have changing levels of consciousness Patients with casts and traction: Casts and traction reduce mobility of the patient or the extremity RISK FACTORS 5

6. Shearing force: Shearing force is a pressure which is exerted against the skin when a patient is moved or is re-positioned in the bed by being pulled or is allowed to slide down in the bed. When shearing force is present, the skin and subcutaneous layers adhere to the surface of the bed, and the layers of muscles and even the bones, slide in the direction of body movement. CONTRIBUTING FACTORS 6

7. Moisture : its presence increases the risk of ulcer formation. Sources of moisture are: wound drainage, perspiration, condensation from humidified oxygen delivery systems, excessively vomiting, incontinence of urine and stool and diarrhea Poor nutrition: less tissue padding between skin and underlying bone affects the pressure on the skin CONTRIBUTING FACTORS 7

8. Edema: blood supply to the edematous tissues is decreased and waste products remain because of the changing pressures in the capillary circulation and capillary bed Anemia: Decreased levels of hemoglobin reduce the oxygen carrying capacity of the blood and amount of oxygen available to tissues. Anemia alters metabolism and impairs wound healing CONTRIBUTING FACTORS 8

9. Cachexia: It is generalized ill health and malnutrition, marked by weakness and emaciation. Basically, the cachexia patient has lost the adipose tissue necessary to protect bony prominence from pressure Old age: Pressure ulcers develop more frequently in older adults over 75 years of age CONTRIBUTING FACTORS 9

10. Infection and fever: Infection and fever increase the metabolic needs of the body, making an already hypoxic tissue more susceptible to an ischemic injury Obesity : It can speed up pressure ulcer development CONTRIBUTING FACTORS 10

11. Stage I The skin is not broken The skin appears red & non blanchable erythema The site may be tender, painful, firm, soft, warm or cool compared with the surrounding skin Stage II The outer layer of skin (epidermis) and part of the underlying layer of skin (dermis) is damaged or lost. The wound may be shallow and pinkish or red The wound may look like a fluid-filled blister or a ruptured blister 11 STAGES OF BEDSORE

12. Stage III T he ulcer is a deep & loss of subcutaneous fat tissue & ulcer looks crater-like The bottom of the wound may have some yellowish dead tissue & undermining & tunneling may be noticed Stage IV A stage IV ulcer shows large-scale loss of tissue: The wound may expose muscle, bone or tendons The bottom of the wound likely contains dead tissue that's yellowish or dark and crusty. The damage often extends beyond the primary wound & undermining & tunneling may be noticed 12 STAGES OF BEDSORE

13. 13

14. In supine position: The areas involved are : Back of the head Scapula Sacral region Elbow and heels In side lying position: Ears Ribs Acromion process of the shoulder COMMON SITES 14

15. In side lying position Greater trochanter of the hip Medial and lateral condyles of the knee Malleolus of the ankle joint COMMON SITES 15

16. In prone position: Ears Cheek Acromion process Breasts (in females ) Genitalia (in males) Knees Toes COMMON SITES 16

17. Location: which is the site affected and single site or multiple sites Wound bed: Color : represent as total percentage (%) and type of Exudate: if present, type, color, odor, and amount Peri wound : description of surrounding skin P ain : presence or absence 3. Measurement : in centimeters Length: longest measurement from 12 o’clock to 6 o’clock (head to toe plane). Width: widest measurement from 9 o’clock to 3 o’clock. Depth: distance from visible surface to deepest portion of wound. Intact, unbroken skin is documented as a depth of “0.” WOUND ASSESSMENT 17

18. The Braden scale assesses a patient's risk of developing a pressure ulcer by examining six criteria . Calculate the client’s Braden scale score by choosing the appropriate value from each subset category and totaling all categories. PRESSURE ULCER RISK ASSESSMENT 18

19. T he Braden Scale is a tool for predicting a client’s pressure ulcer risk. The scale lists and assigns a score for each of the following sub-categories: sensory perception, moisture, activity, mobility, nutrition, friction and shear ADVANTAGES OF BRADEN SCALE No special equipment or activity required Can be performed based on a client interview & observation Typically can be completed in 10 minutes 19 BRADEN SCALE- DEFINITION

20. Sensory perception Moisture Activity Mobility Nutrition Friction/shear 20 CATEGORIES IN BRADEN SCALE

21. Ability to respond meaningfully to pressure-related discomfort 1. Completely Limited : Unresponsive (does not moan, flinch, or grasp) to painful stimuli or limited ability to feel pain over most of body surface 2. Very Limited: Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness, or has a sensory impairment which limits the ability to feel pain or discomfort over ½ of body 3. Slightly Limited : Responds to verbal commands but cannot always communicate discomfort or need to be turned or has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities 4. No Impairment : Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort SENSORY PERCEPTION 21

22. Degree to which skin is exposed to moisture 1. Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. 2. Often Moist: Skin is often but not always moist. Linen must be changed at least once a shift. 3. Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once a day. 4. Rarely Moist: Skin is usually dry; linen only requires changing at routine intervals. MOISTURE 22

23. Degree of physical activity. Bedfast: Confined to bed. Chair fast: Ability to walk, severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair. Walks Occasionally: Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair. Walks Frequently : Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours. ACTIVITY 23

24. Ability to change and control body position. 1. Completely Immobile: Does not make even slight changes in body or extremity position without assistance. 2. Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. 3. Slightly Limited: Makes frequent though slight changes in body or extremity position independently. 4. No Limitations: Makes major and frequent changes in position without assistance. MOBILITY 24

25. Usual food intake pattern NPO : Nothing by mouth IV : Intravenously TPN : Total parenteral nutrition Very Poor: Never eats a complete meal Rarely eats more than 1/3 of any food offered Protein intake includes only 3 servings of meat or dairy products per day Takes fluids poorly Does not take a liquid dietary or is NPO and/or maintained on clear liquids or IV for more than 5 days NUTRITION 25

26. 2. Probably Inadequate: Rarely eats a complete meal and generally eats only about ½ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. O ptimum amount of liquid diet or tube feeding 3. Adequate: Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally refuses a meal or is on a tube feeding or TPN regimen, which probably meets most of nutritional needs 4. Excellent: Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation NUTRITION 26

27. Amount of assistance a client needs to move and the degree of sliding on beds of chairs that they experience. Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. 2. Potential Problem : Moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. 27 FRICTION AND SHEAR

28. 3 . No Apparent Problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times. 28 FRICTION AND SHEAR

29. SNO BRADEN SCALE CATEGORY DESCRIPTION 1 2 3 4 TOTAL SCORE 1 Sensory Perception Ability to meaningfully respond to pressure related discomfort Completely Limited   Very Limited Slightly Limited No Impairment 4 2 Skin moisture Degree to which skin exposed to moisture Constantly moist Often moist Occasionally moist Rarely moist 4 3 Activity Degree of physical activity Bed fast Chair fast Walks occasionally Walks frequently 4 CATEGORIES IN BRADEN SCALE 29

30. SNO BRADEN SCALE CATEGORY DESCRIPTION 1 2 3 4 TOTAL SCORE 4 Mobility Ability to change and control body position.   Completely immobile Very limited Slightly limited No limitations 4 5 Nutritional status Usual food intake Very poor Probably inadequate Adequate Excellent 4 6 Friction & shear Degree to which client is able to move Without sliding Problem Potential problem No apparent problem - 3 7 Total score - - - - - 23 CATEGORIES IN BRADEN SCALE 30

31. Each category is rated on a scale of 1 to 4, excluding the 'friction and shear' category which is rated on a 1-3 scale. This combines for a possible total of 23 points, with a higher score meaning a lower risk of developing a pressure ulcer. BRADEN SCORE TOTAL: Sensory perception = 4 Moisture = 4 Activity = 4 Mobility = 4 Nutrition = 4 Friction and shear = 3 TOTAL = 23 31 RATING OF EACH CATEGORY

32. Very High Risk: Total Score 9 or less High Risk: Total Score 10-12 Moderate Risk: Total Score 13-14 Mild Risk: Total Score 15-18 No Risk: Total Score 19-23 32 BRADEN SCALE ASSESSMENT SCORE

33. Recalculate the Braden Scale score at least once daily In addition to daily scoring, recalculate the Braden Scale whenever there is any change in skin integrity and whenever the client is transferred Complete a head-to-toe integumentary assessment at least three times daily, approximately 8 hours apart, or more frequently as identified Document wound assessment daily Perform wound measurement at least weekly 33 DAILY / INTERVAL ASSESSMENTS

34. BRADEN SCORE 15-18 (AT RISK ): Regular turning schedule Enable as much activity as possible Protect the heels Use pressure redistribution surfaces Manage moisture, friction and shear 34 PREVENTATIVE INTERVENTIONS

35. Braden Scale 10-12(High Risk): Follow the same protocol as for moderate risk. In addition to regular turning schedule. Make small shifts in their position frequently. Braden Scale = 9 (Very High Risk): Use same protocol as for “high risk” patients. Add a pressure redistribution surface for patients with severe pain or with additional risk factors. 35 PREVENTATIVE INTERVENTIONS

36. Change of positions 2 nd hourly Encourage for ambulation Active & passive exercises Comfort Devices such as use of air / water mattresses, alpha beds, pillows, back rest, cardiac table, foot board, foot blocks, foot boots, air cushions P rovide wrinkled free and moisture free bed Change any moist or wet bed linen specially assess after bed bath or any procedure 36 PREVENTATIVE INTERVENTIONS

37. 37 PRESSURE ULCER PREVENTION

38. 38 PRESSURE ULCER PREVENTION

39. Potter and Perry. Fundamentals of Nursing . Reed Elsevier India Private limited, New Delhi. 6th Edi. 2006, 1518-1521. TNAI. Fundamentals of Nursing. A procedure manual . The Trained Nurses’ Association of India. 1 st Edi. 2013, 176 – 178. https://www.redcross.org/images/MEDIA_CustomProductCatalog/m20950218_NAT_Textbook_978-1-58480-582-3-upd.pdf BIBLIOGRAPHY 39