THIS PPT WILL EXPLAINS BRIEFLY ABOUT BEDSORE WOUNDS, DEFINITION , STAGING , WOUND CARE DRESING , DIFFERENT FOAMS ...NURSING RESPONSIBILITIES ..

1. PRESSURE SORE,COMMON CAUSES, PREVENTIVE MEASURES,
COMPETANCY POINTS AND MANAGEMENT
Prepared By
MURUGESH H J
ICU 02
KING FAHD CENTRAL HOSPITAL JAZAN
SAUDI ARABIA

2. INTRODUCTION
 Introduction
Pressure sores (also known as pressure ulcers or bedsores) are injuries to the skin and
underlying tissue, primarily caused by prolonged pressure on the skin. They can
happen to anyone, but usually affect people confined to bed or who sit in a chair or
wheelchair for long periods of time.
“Pressure ulcer is an damage to skin or underlying tissue that usually occurs over a
bony prominence as a result of pressure or pressure in combination with shear or
friction
“ “Device ulcer is an break or cut injury caused due to use of medical equpiment or
prolonged application of the any device to skin “

3. COMMON CAUSES & WOUND STAGING
 Common causes
Old age, malnourished ,improper positioning or not turning for prolonged time,
fragile or delicate skin, wet skin,surgically operated or amputated skin part etc..
Signs & Symptoms :
skin discolourisation , itching , mild to severe pain , purulent discharge, visible wound,
blackish discolourisation etc…
Signs of infection:
Purulent discharge, foul smelling , fever , leucocytosis, hypotesion , tachycardia

4. SKIN ASSESSMENT
 Skin assessment:
Proper assessment is essential to staging the wound,helps to recognise in early
stages ..
Normal skin : small porous,smooth to touch , some oily , if dehydrated, dry
Abnormal skin : discolourized may be reddish, blackish , warm to touch , if 3rd to
unstagable means there will be tunnel filled with pus or secretions ..
Stage 01 : redness
Stage 02 :wound with mild to moderate bleeding , may blackishly discolurized
Stage 03: may be tunnel formed full dirty collections
stage 04 : inffective,foul smelling , wet to touch, patient with have ,mild to moderate
fever ( most fatal)

5. PREVENTIVE STRATEGIES FOR PRESSURE
ULCERS OR DEVICE ULCERS
Preventive strategies for pressure ulcers or device ulcers:
 Stage 01: ( redness or mild pale to touch) :pressure releasing , frequent positioning ,
soft foam application
 Stage 02: ( mild to moderate wound with bleeding ) : as per wound care team
advice regular dressing , in each shift need to assess the condition of the wound, if
any changes immediately need wound care team
 Stage 03 :( moderate to deep with tunnel formation ) : daily or each shift as advised
by wound care team, monitor for signs of sepsis ( need to send wound swab ) ,
fever management
 Stage 04 : ( unstagable) dressing as per wound care team advice , high nutritional
support ,prepre for wound debridement if it is advised,,,,

6. RISK PATIENTS OR MOST VULNERABLE..
Risk patient for pressure ulcer It is most esseential activity , every shift need to
do, please give extra priority,
high risk patient are :
For PU: Old age ( >70yrs) , deeply sedated, very weak muscle tone patients,
nutritionally unsupportive patients ( NPO ,GI problematic , malabsorption patients)..
Undernourished , less activity Stroke patients , obese patients , low platelet count
patients are highly risked…
For DU :. Restrained patients, intubated patients , post craniotomy patients, foleys
catheterized patients …

7. Treatment of 1st & 2nd degree pressure
ulcers
 Treatment of 1st & 2nd degree pressure ulcers :
1st degree : (redness ) pressure release frequent positioning, apply moisturising
creem.soft foam application..please follow wound care team instructions regarding
dressing ..
2nd degree : ( wound with discharge) dressing as per wound care team advice, proper
every shift correct assessment , position changing ,,,,

8. Treatment of 3rd or 4th stage wounds 3rd
or 4th unstagable wounds
Treatment of 3rd or 4th stage wounds 3rd or 4th unstagable wounds :
wear sterile gloves , pour nss ,clean the wound with ucs,allow 5-10seconds to dry , apply
ointment ,cover with bactrigrass , silver cloth etc , cover the wound with sticky foam etc..
Device ulcers:
** please keep soft foams, release the pressure ,
**apply vaseline ,LIPS , LIP MARGINS
** change the ett lip carner in each shift ,
**keep et tie 2fingures loose,
** for foleys catheter please keep heavy pad under the collection bag tube ( thigh margin ) ..
***for craniotomy or EVD patients with dressing please ask NS doctors to change dressing
daily,** change the head position gently

9. Commonly using foams & dressings
Protections foams :
 Commonly using foams & dressings Protections foams :
please apply for all bony prominances ( occiput , elbows, if unconscious cover
scapulla also , sacrum, heels…
for post craniotomy or EVD patient use soft pillow , gently change the head 2nd hourly
…
First degree wounds, use comfeel, soft foams : follow wound care team instructions,
apply spray( surgery or craniotomy wound use opsite spray), apply comfeel foam for
5days ( as instructed by wound care team)
Second degree wounds, cover the dressing with sticky foam : follow wound care team
instructions , clean the wound with nss OR RL, apply fusidine or spray & cover with
sticky foam….

10. Nursing responsibilities
Prevention is the vital , rather than treatment please follow following responsibilities :
 *** please assess the patient in each shift , provide 2hourly position changing ,release the
pressure,f any changes inform nsg responsible or wound care team immediately
 *** for high risk patient, Braden scale score scale score <18 please pay extra attention,
 ***all bony prominences should be apply with protective &soft foams
 *** change ET or TT tie in each shift , ECD or Craniotomy dressing daily ,apply ,,,Vaseline soaked
gauze on lower lip, change lip carner in each shifts ..
 *** follow wound care team instructions , do dressing

11. NURSING RESPONSIBILITIES
*** Nutritional support :provide balanced high protein diet
** Change the dressing if its became soaked & dirty
** while receiving patient from other departments please examine properly , add
notifications while transfer make damage passport with present status ..
** correctly document any changes & report it immediately

12. THANK YOUALL