Pressure Ulcer......................pptx

Pressure Ulcer

1. PRESSURE ULCER Mr. Rushikesh Hange Final year basic nursing Mvps’ Ine , nashik

2. DEFINITION  A pressure ulcer causes impairment of skin integrity.  A pressure ulcer can occur anywhere on the body; tissue damage results when the
skin and underlying tissue are compressed between a bony prominence and an
external surface for an extended period of time.  The tissue compression restricts blood flow to the skin, which can result in tissue
ischemia, inflammation, and necrosis; once a pressure ulcer forms, it is difficult
to heal.

3. RISK FACTORS  Skin pressure and skin shearing and friction
 Immobility
 Malnutrition
 Excessive skin moisture such as that which occurs with incontinence
 Decreased sensory perception

4. Stages of pressure ulcer

5. GENERAL INTERVENTION  Identify clients at risk for developing a pressure ulcer.
 Institute measures to prevent pressure ulcers such as appropriate positioning, using
pressure relief devices, ensuring adequate nutrition, and developing a plan for skin
cleansing and care.
 Perform frequent skin assessments and monitor for an alteration in skin integrity.

6.  Perform frequent skin assessments and monitor for an alteration in skin integrity.
 Keep the client’s skin dry and the sheets wrinkle-free; if the client is incontinent,
check the client frequently and change pads or any items placed under the client immediately after they are soiled.
 Use creams and lotions to lubricate the skin and a barrier protection ointment for the incontinent client.

7.  Turn and reposition the immobile client every 2 hours or more frequently if
necessary; provide active and passive range of motion exercises at least every
8 hours.  If a pressure ulcer is present, record the location and size of the wound (length,
width, depth), monitor and record the type and amount of exudates (a culture of the
exudate may be prescribed), and assess for undermining and tunneling .  Serosanguineous exudate (blood-tinged amber fluid) is expected for the first 48
hours; purulent exudates indicate colonization of the wound with bacteria.

8.  Use agency protocols for skin assessment and management of a wound.  Avoid direct massage to a reddened skin area because massage can damage the capillary beds and cause tissue necrosis.

9. Other treatments may include  Electrical stimulation to the wound area (increases blood vessel growth and
stimulates granulation),
 Vacuum- assisted wound closure (removes infectious material from the wound and
promotes granulation),
 Hyperbaric oxygen therapy (administration of oxygen under high pressure raises
tissue oxygen concentration), and
 The use of topical growth factors (biologically active substances that stimulate cell growth)

10. COMMON SITES OF PRESSURE ULCER

11. 1) In supine position  Occipital bone
 Scapula
 Elbow & Heels (Calcaneus)
 Sacral region 2) In side lying position  Ear  Scapula  Greater trochanter of hip  Medial & lateral condyles of knee  Malleolus & lateral condyles of knee  Malleolus of ankle joint  Ribs

12. 3) In prone position  Frontal bone
 Mandible sternum
 Humorous  Tuberosity of pelvis
 Pelvis

13. COMPLICATIONS ■ Amyloidosis ■ Endocarditis ■ Heterotopic bone formation ■ Maggot infestation ■ Meningitis ■ Perineal-urethral fistula ■ Pseudoaneurysm ■ Septic arthritis

■ Sinus tract or abscess

■ Squamous cell carcinoma in the ulcer

■ Osteomyelitis

■ Bacteremia ■ Advancing cellulitis

14. PREVENTION