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Pressure ulcer presentation3
 

Pressure ulcer presentation3

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  • Pressure ulcers, also bedsores, decubitus, can be defined as an area that has been unrelieved of pressure resulting in damage to underlying tissue. Pressure ulcers can cause pain, disfigurement, prolonged hospitalization and care, costly, and legal issues. The best way to treat pressure ulcers is preventive measures and prompt treatment that can minimize to time to heal. The skin consist of three layers: the epidermis or upper layer, the dermis or inner layer, and the subcutaneous layer or the innermost layer.
  • According to the panel of the Agency for Health Care Policy and Research (AHCPR,1994), “pressure ulcers will affect 9 percent of all hospitalized patients and 23 percent of all nursing home residents.” (p.2) The location of the pressure ulcer found on the head, scapula, vertebrae, elbows, between knees, ankles, heels, hips, sacral, and coccyx.
  • Nurses are responsible to assess the condition of the skin for those resident’s or patient’s that are at risk for pressure ulcer. The responsibility of the nurse’s assistant is to help the health care team to achieve the prevention of pressure ulcers. To do this, the nurse assistant must be able to recognize what pressure ulcers are and how to help prevent them. To start, a nurse assistant can observe the skin while giving a bath. Report any findings immediately to the primary nurse. Do not rub the site, if red. Remember to turn or change the position of the resident/patient as much as possible. Make sure that all linens are smooth with no wrinkles present. Take the bedpan out from underneath the person as soon as the resident/patient is finished. Provide skin care. Make sure the resident/patient is clean and dry after bathing. Apply lightly powder (do not allow powder to cake up in the folds of the abdomen or under the breast. Use lotion to keep skin soft. Provide perineal care, especially to the resident/patient’s that are incontinent. Assist resident/patient to the bathroom. Check on incontinent resident/patient frequently (at least every hour or so, no longer than 2 hours) Provide frequent back massage. Ask resident/patient (who can walk) walk with you every 2 hours. Encourage/remind paralyzed resident/patient to change position in bed or while in wheelchair frequently Make sure bed linens are clean, dry, and wrinkle-free at all times. Lift bed confined resident instead of pulling on sheets. Work as a team to lift residents/patients in bed or turning them. Offer drinks frequently. Encourage meals. Use pressure-reducing devices according to resident’s/patient’s care plan.
  • Many different scales can be used to evaluated patients at risk for pressure ulcers. In the local facilities, nursing homes and hospital, the Braden scale is used. This evaluates the patient’s activity, moisture, sensory perception, mobility, nutrition, and friction and shears. This scale is performed as the patient presents himself or herself at time of admission, not pre-morbidly. Remember to use skin assessment scale according to facility’s policy. “Suspected Deep Tissue Injury: Marooned or purple localized area of intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Further description: Deep tissue injury may be difficulty to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.” (www.npuap.org)
  • Stage 1 is a nonblanchable erythematic of intact skin (redness of skin along bony prominence). “In individuals with darker skin, discoloration of the skin, warmth, edema, indurations, or hardness may also be indicators.: (AHCPR, 1994, NPUAP, 2007) To check whether or not this is a pressure ulcer, leave area alone for 30 minutes. If redness does not disappear, classify this as stage one. Further description: Painful, firm, soft, warmer or cooler to adjacent tissue. May indicate “at risk” person. The treatment for Stage I is to relieve pressure of site by repositioning, providing relieving devices such as pillows, heel or elbow protectors, or barriers to protect the skin. Also follow hospital policy.
  • Presents as a shiny or dry shallow ulcer without slough or bruising. If bruising is present may indicate deep tissue injury. This should not be used to describe skin tears, tape burns, perineal dermititis, excoriation, or maceration.
  • Further description: The depth of a stage III pressure ulcer varies by anatomical location such as the bridge of nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III may be shallow. In contrast to areas that have adipose, stage III can develop deeply. Remember bony/tendon are not visible or directly palpable.
  • Further description: depth may vary by anatomical. Can be the same as stage III but the difference is that bony prominence or tendon is visible or directly palpable. Stage IV can extend into muscle and/or supporting structures such as fascia, tendon, joint causing osteomyelitis.
  • Until slough or eschar is removed this ulcer cannot be staged. Stable (dry, adherent, intact without erythema or fluctance) eschar on heels serves as “the body’s natural (biological) cover” and should not be removed.

Pressure ulcer presentation3 Pressure ulcer presentation3 Presentation Transcript

  • Pressure Ulcer Presentation Brenda Holmes MSN, RN September 7, 2007
  • Pressure Ulcer Presentation
    • Objectives
      • Students will be able to:
        • identify each stage of pressure ulcers.
        • know procedures in preventing pressure ulcers.
        • to follow through with the care.
  • Pressure Ulcer Presentation
    • What do you know about pressure ulcer?
  • Pressure Ulcer Presentation
    • Epidermis
    • Dermis
    • Subcutaneous layer
  • Pressure Ulcer Presentation
    • Bony prominence
      • Head, Scapula, Vertebrae
      • Elbows, Between knees, Ankles, Heels
      • Hips, Sacral, Coccyx
  • Pressure Ulcer Presentation
    • At risk for pressure ulcer
      • A person that remains in one position due to inability to move self
      • Old age
      • Poor nutrition and lack of fluids
      • Moisture
      • Cardiovascular or respiratory problems
      • Friction and shearing injuries
  • Pressure Ulcer Presentation
    • Types of pressure relieving devices
      • Heel protectors
      • Elbow protectors
      • Bed cradle
      • Footboard
      • Air flow mattress
      • Alternating pressure bed
  • Pressure Ulcer Presentation
    • Braden Scale
    • New Stages of Pressure Ulcer
      • New as of February 2007
        • (Suspected) Deep Tissue Injury
        • Stage 1
        • Stage II
        • Stage III
        • Stage IV
        • Unstageable
  • Pressure Ulcer Presentation
    • Suspected deep tissue injury
      • Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear
  • Pressure Ulcer Presentation
    • Stage I
      • Nonblanchable erythematic
    • Treatment
      • Repositioning
      • Relieving devices
      • Heel or elbow protectors
      • Skin barriers
  • Pressure Ulcer Presentation
    • Stage 2
      • Partial thickness loss of dermis as a shallow crater
      • Pink wound bed
      • No slough (yellow)
      • May be intact or open blister
  • Pressure Ulcer Presentation
    • Stage III
      • Full thickness tissue loss
      • Subcutaneous fat may be visible but bone, tendon, or muscle not exposed
      • Slough may be present but not the depth of the tissue loss
  • Pressure Ulcer Presentation
    • Stage IV
      • Full thickness loss with exposed bone or tendon
      • Slough or eschar can be visible in some parts of the wound bed
      • Can include tunneling or undermining
  • Pressure Ulcer Presentation
    • Unstageable
      • Full thickness tissue loss with base covered by eschar (black, tan, brown, or slough (yellow, green, tan, gray, or brown)
  • Pressure Ulcer Presentation
    • Nurses’ responsibility
      • Address issue immediately
      • Start pressure ulcer preventative measures as soon as MD is notified
      • Turn patient q 2hours
      • Inform dietician if open wound is present
      • Measure/describe wound on admission
        • and weekly
  • Pressure Ulcer Presentation
    • Nursing Assistant’s responsibility
      • Turn resident/patient every 2 hours
      • Provide peri-rectal care after each incontinent episode
      • Apply lotion or cream after each incontinent episode (DO NOT MASSAGE)
      • Report any skin integrity issue to primary care nurse
      • Assist primary care nurse as needed with wound care (as set by each facility)
  • Pressure Ulcer Presentation
    • Treatments
      • Heel protectors
      • Turn q 2 hours
      • Specialty mattress
      • Creams, ointments, dressings, wound vac as ordered by MD
      • Nutritional support i.e. dietary consult, increase protein, vitamin support (Vitamin C and Zinc)
  • Pressure Ulcer Presentation
  • Conclusion
    • PREVENTION
  • Pressure Ulcer Presentation
    • Reference
    • National Pressure Ulcer Advisory Panel (2007). http://www.npuap.org
    • Black, J. M. & Black, S. B. (2004). Deep tissue injury, case study. Wounds from http://www.medscape.com/viewarticle/466563