2. 1. ASSESSMENT:
a) Assess total skin condition at least twice a
day.
b) Inspect each pressure site for erythema
(redness of the skin).
c) Assess areas of erythema for balance
response.
d) Palpate the skin for increased warmth.
e) Inspect for dry skin, moist skin, breaks in
skin.
3. ASSESSMENT:
f) Note drainage and odour.
g) Evaluate level of mobility.
h) Note restrictive devices( e.g. restraints,
splints).
i) Evaluate nutritional and hydration status.
4. 2. RELIEVING PRESSURE :
Frequent changes of position are needed to
relieve and redistribute the pressure on the
patient’s skin and to prevent prolonged reduced
blood flow to the skin and subcutaneous tissues.
5. 3. POSITIONING THE PATIENT :
a) The patient should be positioned lateral, prone
and dorsal in sequence unless a position is not
tolerated or is contraindicated.
b) The recumbent position is preferred to the
semi-Fowler’s position because of increased
supporting body surface area in this position.
6. 4. PREVRNT FRICTION:
a) When changing position of your patient lift him
and do not drag him on to bed.
b) Keep sheets without wrinkles.
c) Keep bed clean and free from crumbs.
d) If patient is restless, protect pressure points
with soft pads.
e) Proper positioning with adequate support is
also important when a patient is sitting in a
chair
7. 5. MINIMIZE IRRIATING MOISTURE:
a) Continuous moisture on the skin must be
prevented by meticulous hygienic measures.
Perspiration, urine, stool and drainage must be
removed from the skin promptly.
b) The soiled skin should be washed immediately
with mild soap and water and blotted dry with a
soft towel.
c) The skin may be lubricated with a bland lotion
to keep it soft and pliable.
8. 6. BRIDGING TECHNIQUE:
a) Another way to relieve pressure over bony
prominences is the bridging technique, accomplished
through the correct positioning of pillows.
b) Just as a bridge is supported on pillars to allow traffic
to move underneath, so can the body be supported by
pillows to allow for space between bony prominences
ant mattress.
c) A pillows or commercial heel protector may be used to
support the heels off the bed when the patient is
supine.
9. 7. USING PRESSURE-RELIEVING
DEVICES:
At times, special equipment and beds may be
needed to help relieve the pressure on the skin.
These are designed to provide support for
specific body areas or to distribute pressure
evenly.
10. 8. IMPROVING MOBILITY:
a) The patient is encouraged to remain active and is
ambulated whenever possible.
b) When sitting, the patient is reminded to change
positions frequently to redistribute weight. Active
and passive exercise increase muscular, skin
and vascular tone.
c) For the patient at risk for pressure ulcers, turning
exercise schedules are essential: repositioning
must occur around the clock.
11. 9. IMPROVING SENSORY PERCEPTION:
The nurse helps the patient recognize and
compensate for altered sensory perception.
Depending on the origin of the alteration ( e.g.
decreased level of consciousness, spinal cord
lesion), specific interventions are selected.
12. 10. IMPROVING TISSUE PERFUSION:
Exercise and repositioning improve tissue
perfusion. Massage of erythematous areas is
avoided because damage to the capillaries and
deep tissue may occur.
13. 11. INPROVING NUTRITIONAL STATUS
a) The patient’s nutritional status must be adequate
and a positive nitrogen balance must be
maintained, because pressure ulcers develop more
quickly and are more resistant to treatment in
patient with nutritional disorders.
b) A high protein diet with protein supplements may be
helpful.
c) Iron preparations may be necessary to raise the
hemoglobin concentration so that tissue oxygen
levels can be maintained within acceptable limits.
14. 12. PREVENT PREDISPOSING CAUSES:
a) Improve patient’s health by means of good
food, ventilation, sunlight and exercise.
b) Encourage circulation through massage.
15. 13. GIVE GOOD CARE TO PRESSURE
POINTS:
a) Careful cleaning and massage should be
carried out 3 or 4 times a day for all bedridden
patients.
b) For some patients, it is necessary to give as
often as every two hours.
