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Bed sore management
This document discusses bed sore management and prevention. It defines bed sores as injuries to the skin and underlying tissues caused by prolonged unreleived pressure. Risk factors include advanced age, malnutrition, physical disability, and chronic illness. Bed sores are staged from Stage 1 involving changes in skin color to Stage 4 involving full thickness tissue loss reaching muscle, bone and tendon. Treatment involves surgical procedures like debridement, dressings, antibiotics, regular posture changes, diet, and hygiene to prevent further complications. The nursing perspective focuses on assessing risk factors, inspecting the skin and environment, staging any sores present, and ensuring regular care and prevention measures.
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Bed sore management
- 1. BED SORE MANAGEMENT APREVIEW KAMRAN YOUSAF FCPS(PAK),MRCS(GLASGOW,UK)
- 2. DEFINITION • TERMINOLOGY • BEDSORE,,,PRESSURE SORE,,,PRESURE ULCER • DECUBITUS ULCER • INURY TO SKIN AND UNDERLYING TISSUES DUE TO PROLONGED UNRELIEVED PRESSURE
- 3.
- 4. RISK FACTORS • ADVANCEDAGE > 70 YEARS • MALNUTRITION AND DEHYDRATION • PHYSICAL DISABILITY • CHRONIC MED ILLNESS
- 5.
- 6. MECHANISM OF INJURY •PROLONGED SUSTAINED PRESSURE LEADS TO EXCESS PRESSURE THAN NORMAL CAPILLARY PRESSURE THUS NARROWS THE SMALL VESSELS OF SKIN THEREFORE REDUCED TISUE PERFUION & SKIN BREAKDOWN
- 7.
- 8. COMMON SITES OFBED SORES • BACK OF THE HEAD • SHOULDERS • EAR LOBES • SCAPULAR AREAS • TAILBONE/SACRUM • GREATER TROCHANTERS • KNEE • ANKLE AND HEELS
- 11. STAGES OF BEDSORES
- 12. STAGE 1 • SUPERFICIAL,,,EPIDERMAL •CHANGE OF COLOUR ONLY • DOESN’T BLANCH • DARK SKIN • WARM,,,OEDEMATOUS • NO SKIN BREAK
- 15. STAGE 2,PARTIAL THICKNESSSKIN LOSS AND / BLISTER • INVOLVES DERMIS • SKIN BREAKDOWN
- 19. STAGE 3,,,FULL THICKNESSSKIN LOSS FAT EXPOSED • EPIDERMIS,DERMIS,SUBCUT TISSUE • FULL SKIN BREAKDOWN • MUSCLE,BONE,TENDON NEITHER EXPOSED NOR DAMAGED
- 21. STAGE 4,,,FULL THICKNESSTISSUE LOSS • DEEP ULCER • REACHES MUSCLE • BONE AND • TENDON
- 26. UN-CLASSIFIED • OCCASIONALLY,,, A DRYSCAB COVERS MORE SERIOUS AND DEEP INFECTED BED SORE
- 27. ASESSMENT FOR BEDSORE • BRADEN SCORING SYSTEM • NORTON SCORE
- 31. 2 HOURS ---2 WEEKS
- 32. COMPLICATIONS • CELLULITIS/ABSCESS • SEPSIS •BONE AND JOINT INFECTIONS • CANCER
- 33. COMPLICATIONS • MUSCLE ATROPHY •JOINT CONTRACTURES • PNEUMONIA • DVT
- 34. TREATMENT • ADMIT THEPATIENT • DEVISE A COMPLETE TREATMENT PLAN • MONITOR • FREQUENTLY RE-ASSESS
- 35. TREATMENT • SURGICAL • MEDICAL •NURSING CARE
- 36. SURGICAL • DEBRIDEMENT ANDI/D • AUTOLYTIC • MECHANICAL • ENYMATIC • SHARP • BIOSURGICAL
- 37.
- 38. THE DRESSINGS • HYDOPHYLLIC •HYDROGEL • ALGINATE • FOAM • ACCUZYME • PANAFIL
- 39. MEDICAL • CONTROL OFMED ILLNESS • BALANCED DIET • ANEMIA • DEHYDRATION AND ELECTROLYTE IMBALANCE • ANTIBIOTICS
- 40. NURSING CARE • REGULARPOSTURE CHANGE,,, 2 HOURLY • REGULAR DRESSING • DAILY INSPECTION OF SKIN • EARLY CHANGE OF PAMPERS/NAPKINS • HYGIENE CARE • DIET FOLLOW UP • FAMILY EDUCATION/TRAINING
- 44.
- 46.
- 47. BEWARE,,,, • PATIENT ISOLD AGE • LIMITED PHYSICAL MOBILITY • MEDICAL ILLNESSESS • PROLONGED STAY
- 48.
- 49. INSPECT • SKIN ,,,,,ESPECIALLY AT THE PRESSURE AREA • BOWEL/URINE • BED SHEET/PILLOW COVERS/DRESS • AIR MATTRESS
- 50. STAGE THE BEDSORE
- 51. ENSURE • REGULAR MEDICATION •TIMELY DRESSINGS • REGULAR POSTURE CHANGE • HYGIENE • DIET INTAKE