The document discusses pressure ulcers, also known as bedsores or pressure sores. It defines pressure ulcers as damage to skin and underlying tissue caused by prolonged pressure. It notes that pressure ulcers most often form over bony areas of the body and can be graded based on the amount of tissue damage. The document lists risk factors for developing pressure ulcers and areas of the body to check. It emphasizes the importance of skin care, nutrition, repositioning, and being on the lookout for any changes in residents' skin.

2.  Human body’s
largest organ
 Body’s first line of
defense

3.  Protection
 Regulation
 Sensation
 Metabolism
 Communication

4.  A sore caused by constant,
unrelieved pressure to the skin and
underlying tissue.
 The pressure comes from outside
the body.

5.  Pressure slows the
blood flow to an area
which leads to tissue
death
 “Friction” and
“shear” can add to
the problem

6.  Pressure ulcers most often form over
bony areas on the body

7.  Pressure ulcers are
graded or “staged”
to indicate the
amount of tissue
damage
 Stage 1, Stage 2,
Stage 3, and Stage
4

8.  There are “Risk
Factors” that when
present, make a
resident MORE
likely to develop a
pressure ulcer

9.  Poor nutrition
 Unintentional
weight loss

10.  Inability to easily
move or reposition
 Incontinence

11. A resident who spends most
of their time sitting in a chair
or in a wheelchair, is also at
risk for developing a
pressure ulcer.

12.  Inability to feel and
report pain
 Lowered mental
awareness

13.  When you see even one or two of
these risk factors, be on the lookout.
This resident is at greater risk of
developing a pressure ulcer.

14. Every time you change, help to
the toilet, dress, bathe, transfer,
and/or turn a resident... you have
a chance to check and care for a
resident’s skin.

15.  An area of skin
that is noticeably
different than the
surrounding area
• It may look red, and the redness
does not “fade” when the skin is
touched, and released (blanched).

16. For residents with
darker skin, the skin
may look darker or
lighter than the
surrounding skin.
Skin may look a little:
red, blue, or purple
in color.

17. Gently feel for a change in
skin temperature: it may
feel warmer or cooler than
the surrounding area.
A “suspicious area” may feel
"spongy“ or "raised".

18.  Look for areas of redness that are “non-
blanchable*”
Note: Redness should fade, when the
skin is *touched and released.

19. Back of the head, ears,
shoulder blades, elbows, tailbone,
buttocks, hips, and heels.

20. Pressure ulcers usually form over
a bony part of the body.

21. When you check a
resident’s skin, be sure
to have good lighting.

22.  Skin Care
 Check the skin on daily basis.
 Check the skin while performing other care
giving tasks
Healthy skin is clean and moisturized,
not dry, cracked, or scaly.

23.  Nutrition and eating
 Encourage residents to eat and drink
 Assist residents with eating
 Feed residents unable to feed themselves
 Repositioning
 Turning
 Encourage residents to shift position

24.  Positioning
 Encourage residents to make small
shifts in position
 Keep head of bed at 30° or less
 Heels elevated off mattress supported by pillows
under the legs
 Use a pillow to keep the knees and heels from
rubbing together
 Turning Schedule for residents who cannot move
by themselves

25. After turning or helping a
resident shift their
weight, use a pillow to
support the new position
in the bed or chair.

26.  encourage small
shifts in weight if the
resident is able
 if a resident is on a
turning schedule, be
sure to stick to the
schedule
Prevention is the key

27.  care for a resident’s skin
(Healthy skin is clean and
moisturized, NOT soiled, dry,
cracked, or flakey.)
Prevention is the key

28.  encourage or assist a resident to eat
their food and drink their water
Prevention is the key

29.  check a resident’s skin each time
you change, help to the toilet, dress,
transfer, bathe, or otherwise have
an opportunity.
Always be on the look-out

30.  look for an area of skin that looks
noticeably different than the
surrounding areas
 especially on skin over the bony
parts of the body
Always be on the look-out

31. You have a great opportunity to
positively IMPACT the health and
well-being of nursing home
residents.

32.  If you see even a small change in a resident’s
skin –
TELL SOMEONE
TELL SOMEONE, until you are SURE they
hear you.