free education

1. Pressure ulcer
prevention and care
BHAGAVATHI NAGOORPITCHAI
STAFF NURSE-CRITICAL CARE

2. Introduction Pressure ulcer are injuries to the skin and
underlying tissue, usually over a bony
prominence.
They can happen to anyone but usually
affect people confined to bed or who sit in
a chair or wheelchair for long period of
time.

3. Definition
Pressure ulcer are an injury
that break down the skin and
underlying tissue, they are caused
when an area of skin is placed
under pressure.
They also known as bedsore or
pressure sores.

4. Risk factor
Character Normal Medium risk High risk
Skin Intact and pink Swollen Red or broken
Moisture Clean and dry skin Moist and clammy skin Wet skin and incontinent
Weight Normal weight Overweight Under weight
Mobility Active Less active or need
assistance
Spends long periods in
bed or seated
Nutrition and
hydration
A healthy varied diet with
plenty of liquid
A compromised diet Poor nutrition hydration
Sensory perception Fully sensory perception, no
impairment
Limited sensory
perception
No sensory perception

5. Risk factor(continue..)
Age:-
As we get older changes in the connective
tissue mean our skin loosen its strength and
elasticity and become thinner . this makes the skin
more susceptible to damage.
Comorbidity:-
Many health problem such as neurological
disorder(Cerebrovascular accident with plegia,
multiple sclerosis, etc.), vascular
disease(peripheral arterial disease) Diabetes
mellites and disorder that affect mobility and
sensation can all add to the risk of a pressure
ulcer developing.

6. Causes  Pressure
Prolonged pressure on bony prominences or body
parts.
e.g:-bed or wheelchair
 Friction
Friction due to moving the body or body parts to
sitting or lying
 Moisture
To wet due to urine, sweating, other solution like
water in body or surface(bed or wheelchair).

7. Pathophysiology
Various risk factors act on areas of soft tissue overlying bony
prominence
When this pressure exceeds normal capillary pressure
Occlusion &tearing of small blood vessels
Reduced tissue perfusion
Ischemic necrosis
Pressure sore

8. Pressure points
Don’t Forget the Nose, If the patient had face mask or on
BiPAP, Assess the face for any ulcers

9. Normal skin

10. Stages(Continue..)
 Stage 1:-
 The area looks red and feel warm to the touch.
 Non blanchable.
 Skin discoloration present.
e.g.:-red, blue, or black.
 Stage 2:-
 Partial thickness loss of epidermis and dermis.
 As a shallow open ulcer with a red or pink wound.
 Wound without slough or bruising (abrasion , blister).

11. Stages(Continues..)
 Stage 3:-
 Involve the full thickness of the skin loss.
 May extend into the subcutaneous tissue layer in which
adipose(fat).
 Granulation tissue and epibole (rolled wound edges) are often
present.
 Pressure ulcer do not reach muscle ,tendon and bone.
 Stage 4:-
 It’s the most severe from of bedsore also called decubitus ulcer.
 Bedsore is a wound reaching the muscle , ligament , bone.
 They often cause extreme pain infection, invasive surgeries or
even death.

12. Stages(Continues..)
 UNSTAGABLE PRESSURE ULCER
 Full thickness tissue loss in which
actual.
 Depth ulcer is completely obscured by
slough (yellow, gray, green or brown)
or eschar (brown or black) in the wound
bed.

13. Assessment scales
 Braden Risk Assessment Scale
 Norton Sub Scale

14. Assessment scales(Continues..)
Braden Risk Assessment Scale
 Tool developed by Barbara
Braden and Nancy Bergstrom in
1987
 Its help to assess risk of pressure
ulcer in heath workers, especially
nurses.
 Score
 No Risk :- Total score 19-23
 Mild Risk :- Total score 15-18
 Moderate Risk :- Total score 13-14
 High Risk :- Total score 10-12
 Very High-Risk :- Total score 9 or less

15. Assessment scales(Continues..)
Norton Sub scale
 The Norton Scale was developed in
the 1960s
 Its widely used to assess the risk
for pressure ulcer in adult patients.
 The five subscale scores of the
Norton Scale
 Score
 Greater than 18 - Low risk
 Between 18-14 - Medium risk
 Between 14-10 - High risk
 Less than 10 - Very high risk

16. Measuring the wound’s dimension
 The wound is typically measured first by its length , then by width, and
finally by depth .
 The length is always from the patient’s head to the toe .
 The width is always from the lateral positions on the patient .
 The depth is usually measured by inserting a q- tip in the deepest part of
the wound with the tip of finger .

17. Signs and Symptoms
Stage 1:-
Affected area has no surface breaks or tears but may ,
 Appear skin in Redness ,blue or black color
 Warm temperature
 Feel firmer than surrounding tissue.
 Mild burning or itching.
 Swelling

18. Signs and Symptoms(Continues..)
Stage 2:-
 A shallow ,crater like wound
 Red or pink wound.
 Serum filled blister
 Pain
 Swelling and discoloration around the sore

19. Signs and Symptoms(Continues..)
Stage 3:-
 There is a high possibility of infection at this stage.
 Pus or a greenish fluid from the sore.
 Possible necrosis, which is dead tissue.
 Odor.
 Fever.

20. Signs and Symptoms(Continues..)
Stage 4:-
 Pain.
 Purple color in the area.
 Firm or mushy texture in the area.
 Necrosis.
 Visible muscle and bone.
 Common sign of infection(foul smell and pus).

21. Diagnosis
 History collection (Neurological, surgical and
medical history).
 Physical examination(Head to toe examination
especially all pressure points).
 Blood test(ESR,CBC-Hb, WBC).
 X-ray as needed(Especially stage 3 and 4).
 MRI
 Wound swab culture(Which micro-organism
are present).
 Bone biopsy(Which micro-organism are
present-if surgical repairment).

22. Prevention of pressure ulcer
 Mattress(air /water)
 Use moisturizing cream
 Clean and dry areas underneath breast and groin.
 Position change every 2Hrs,if patient is bedridden or unconscious.
 Learn transfer techniques to avoid dragging your skin across surface.
 To avoid prolonged sitting on wet clothes or moist surfaces.
 Properly maintain and check your cushions.
 Educate the patient and their family regarding prevention methods for
pressure ulcers.

23. Topical Treatment for prevention
of Pressure ulcer
 Many studies conclude that use of a
cream high with fatty acid helps in
prevention of pressure ulcer
 Fast Fact: Olive Oil can be used as a
prevention method for Pressure Ulcer,
BUT It’s Less effective that cream high
with fatty acid.

24. Topical Treatment for prevention of
Pressure ulcer
Multilayer foam dressings with silicone
is also effective in preventing pressure
ulcer.

25. Prevention of pressure ulcer(Continues..)
 Don’t massage reddened areas ,
heat lamps or try to dry them out.
 Regular exercise ,if patient
bedridden do ROM
exercise(abduction, adduction
etc.…)

26. Prevention of pressure ulcer
Diet Recommended
 Maintain a healthy weight (BMI:-18.5-24.9). Overweight or under weight
are at higher risk.
 It is recommended a protein intake for pressure ulcer healing of 1.5 to 2
g/kg of body weight per day.
 Vitamin A increases the number of macrophages and monocytes in the
wound, supports mucosal and epithelial surfaces, increases collagen
formation (kale, spinach, broccoli, Milk, beef liver).
 Vitamin C increases resistance to infection by promoting migration of
white blood cells to the wound. (citrus fruit, broccoli, potatoes).
 Zinc is an essential element required for cell replication and growth and
protein synthesis (beans, nuts, crab, whole grains, breakfast cereals, and
dairy).
 Hydration plays a vital role in the preservation and repair of skin integrity.

27. Care of pressure ulcer(Continues..)
 Cleaning
 If open wound should be cleaned with saline or sterile water,
rinse to remove loose, dead tissue.
 If no broken skin, wash it with a gentile cleanser and pat dry.
 Putting on a bandage
 Its help fast healing by keeping the wound moist.
 It create a barrier against infection.
 Keeps the surrounding skin dry.
 Its choice include films, gauze, gels, foams and treated
coverings.

28. Care of pressure ulcer (Continue..)
 Drug to control pain and infection
NSAID(Nonsteroidal anti-inflammatory drug)-
such as ibuprofen and naproxen sodium-It reduce pain.
Paracetamol
Antibiotics –according to culture result.
 Diet
Good nutritious food may help to promote wound
healing.
 Negative Pressure Therapy(vacuum assisted closure)
Use advice to clean a wound with suction

29. Care of pressure ulcer(Continues..)
 Surgical Repair
 Removing Damaged Tissue
 Debridement
- To be free of damaged , dead or infected tissue
- It accomplished with number of methods, such as gently
flushing the wound with water or cutting out damaged tissue
 Grafting
- If it fails to heal, might require surgery
- Flap reconstruction:-To use a part of your muscle skin or other tissue to
cover the wound.

30. Care of pressure ulcer(Continues..)
Types of dressing:
 Collagen dressing: Wounds that have stalled in the healing phase and
Wounds with minimal to heavy exudate.( stage II-II).
 Hydrogel dressing: The jelly mass of hydrogel can absorb effusion, maintain
high wound moisture and allow the growth of cells and their migration.(used
for stage II to IV; Not used if there’s excessive exudate).
 Hydrocolloid dressings: can be used for prevention of skin (pressure)
damage it helps reduce the effects of friction forces on the skin. (stage I).
 Foam Dressing: mainly for the treatment of moderately to heavily
exudating wounds (used for stage II to IV).

31. Complication
 Cellulitis
 Bone and Joint Infection
 Marjolin's ulcers
 Sepsis
 Increase Mortality and Morbidity rate.

32. Reference
 Clark, M. R., Black, J., Alves, P. C., Brindle, C. T., Call, E., Dealey, C., & Santamaria, N. (2014). Systematic review of the use of prophylactic dressings in the prevention
of pressure ulcers. International Wound Journal, 11(5), 460–471. https://doi.org/10.1111/iwj.12212
 [Collagen powder dressing in the treatment of pressure ulcer. Multicenter comparative study assessing effectiveness and cost]. (2002, September 1). PubMed.
https://pubmed.ncbi.nlm.nih.gov/13677749/
 Cruz, D. M., Saleh, B., Vernet-Crua, A., Ajo, A., Roy, A., & Webster, T. J. (2020). Drug-delivery nanocarriers for skin wound-healing applications. In Elsevier eBooks (pp.
439–488). https://doi.org/10.1016/b978-0-12-816413-6.00022-8
 Keogh, S., Nelson, A., Webster, J., Jolly, J., Ullman, A. J., & Chaboyer, W. (2018). Hydrocolloid dressings for treating pressure ulcers. Cochrane Database of Systematic
Reviews. https://doi.org/10.1002/14651858.cd010364.pub2
 Walker, R., Gillespie, B. M., Thalib, L., Higgins, N., & Whitty, J. A. (2017). Foam dressings for treating pressure ulcers. Cochrane Database of Systematic Reviews,
2017(10). https://doi.org/10.1002/14651858.cd011332.pub2
 Saghaleini, S. H., Dehghan, K., Shadvar, K., Sanaie, S., Mahmoodpoor, A., & Ostadi, Z. (2018). Pressure ulcer and nutrition. Indian Journal of Critical Care Medicine,
22(4), 283–289. https://doi.org/10.4103/ijccm.ijccm_277_17
 Moore, Z., & Webster, J. (2018). Dressings and topical agents for preventing pressure ulcers. The Cochrane Library, 2018(12).
https://doi.org/10.1002/14651858.cd009362.pub3