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. R I S K
F A C T O R S
.

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. C O M M O N
A R E A S
HEELS & KNEES
P
R
E
S
E
N
T
A
T
I
O
N

19. C O M M O N
A R E A S
SHOULDERS &
ELBOWS
P
R
E
S
E
N
T
A
T
I
O
N

20. C O M M O N
A R E A S
OCCIPITAL &
EAR REGION
P
R
E
S
E
N
T
A
T
I
O
N

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 !