What is meant by bed sore? Bedsores — also called pressure ulcers and decubitus ulcers — are injuries to skin and underlying tissue resulting from prolonged pressure on the skin. Bedsores most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone.

1. PREVENTION AND CARE
OF PRESSURE INJURIES IN ICU PATIENTS
Dr.AnjalatchiMuthukumaran
Vice principal
Era collegeofNursing
Lucknow -226003

2. PRESSURE INJURIES
 localized injuries of the skin or underlying tissue, most often over a
bony prominence by prolonged pressure,
 Pressure sores/ ulcer, decubitus ulcers and bed sores, ranging in
severity from reddening of the skin to severe, deep craters with
exposed muscle or bone.
 Patients in ICU are at a higher risk of developing pressure injuries
(PI) than patients admitted to general wards.
 PIs are associated with increased morbidity, mortality and health care
cost.

3. SKIN

4. PATHOPHYSIOLOGY
Pressure
 There is compression of tissues. It
leads to decreased tissue perfusion,
ischemia occurs leading to tissue
necrosis
Shear force
 The force created when the skin of a
patient stays in one place as the deep
fascia and skeletal muscle slide down
with gravity. leading to ischemia and
tissue necrosis.
Friction
 It causes shedding of layers of
epidermis.

5. Unrelieved pressure
Disrupts blood supply to the capillary network
Depriving tissues of oxygen, nutrients and
blocks
the return of metabolic wastes
Complete inflow impairment
Local ischemia and tissue damage
Pressure ulcer
Pressure injuries
are caused by
unrelieved pressure,
applied with great
force over a short
period (or with less
force over a longer
period)

6. EXTRINSIC RISK FACTORS
1. Pressure from any hard surface e.g. bed, wheelchair, stretcher
2. Friction from patients inability to move
3. Shear from involuntary muscle movements
4. Moisture: contributes to maceration, and this may make the damaged
epidermal layers more vulnerable to further pressure related
degradation. (urinary incontinence, fecal incontinence, and urinary
catheters)

7. INTRINSIC RISK FACTORS
1. Limited mobility:
I. Spinal cord injury,
II. Progressive neurologic
disorders,
III. CVA,
IV. Fractures,
V. Coma,
VI. Mechanical ventilation
2. Poor nutrition:
I. Anorexia,
II. Dehydration,
III. Dietary restrictions
1. Comorbidities:
I. Diabetes,
II. Depression,
III. Vasculitis,
IV. PVDs,
V. CHF,
VI. Immunodeficiencies
2. Aging skin: Elderly individuals
have less subcutaneous fat,
decreased dermal thickness
and decreased sensory
perception

8. MOST COMMON SITES
 Pressure injuries are characteristically rounded with regular edges.
 The most common sites for pressure injuries are :
Supine:
23% sacro-coccygeal, 8% heels, 1% occiput; spine
Sitting:
24% ischium, 3% elbows
Lateral:
15% trochanter, 7% malleolus, 6% knee, 3% heels

9. CONT..

10. STAGES / CLASSIFICATION OF PRESSURE ULCER
 Based on the depth of tissue
destroyed.
 Four stages of bedsores
1. Stage I
2. Stage II
3. Stage III
4. Stage IV

11. STAGE I : NON-BLANCHABLE REDNESS OF INTACT SKIN
 Intact skin with non-blanchable redness of a localized area usually
over a bony prominence. Darkly pigmented skin may not have visible
blanching; its colour may differ from the surrounding area.

12. STAGE II: PARTIAL-THICKNESS SKIN LOSS OR BLISTER
 Partial thickness loss of dermis presenting as a shallow open ulcer
with a red pink wound bed, without slough. May also present as an
intact or open/ruptured serum-filled blister.

13. STAGE III: FULL-THICKNESS SKIN LOSS (FAT VISIBLE)
 Full thickness tissue loss. Subcutaneous fat may be visible but bone,
tendon or muscles are not exposed. Slough may be present but does
not obscure the depth of tissue loss. Difficult to heal as fat has less
vascularity

14. STAGE IV: FULL-THICKNESS TISSUE LOSS
 Full thickness tissue loss with exposed bone, tendon or muscle.
Slough or eschar may be present on some parts of the wound bed.
Often include undermining and tunnelling.

15. SUSPECTED DEEP TISSUE INJURY
 Purple or maroon localized area of discoloured intact skin or blood-
filled blister due to damage of underlying soft tissue from pressure
and/or shear. The area may be preceded by tissue that is painful,
firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

16. UN-STAGEABLE PRESSURE ULCER
 Full thickness tissue loss in which the base of the ulcer is covered by
slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown
or black) in the wound bed. Base of the wound cannot be visualized.

17. PREVENTION AND MANAGEMENT
The main key elements :
• Risk assessment
• Skin assessment
• Preventive measures
• Treatment
RISK ASSESSMENT:
 Prompt and accurate identification of risk factors associated with PU
development is the first step in effective prevention.
 Risk assessment and skin inspection should be performed within 8
hours of admission and at least daily thereafter.

18. CONT..
SKIN ASSESSMENT
 The condition of the patients skin is
probably the most important
indicator of how the skin will react to
pressure exposure
 Patient’s skin should be inspected
from head to toe
 Focus on the most high risk areas
over bony prominences, skin folds,
between the toes, and all areas of
skin in contact of medical devices.

19. PREVENTIVE MEASURES AND
TREATMENT
1. NUTRITIONAL SUPPORT:
 Patients who are malnourished have more bony prominences and are
therefore more at risk for PU.
 Additionally, poor nutritional status results in decreased protein,
rendering tissue more susceptible to the effects of pressure.
 A healthy diet is important in preventing skin breakdown and in aiding
wound healing
 Adequate hydration to maintain the skin integrity

20. 2.FREQUENT REPOSITIONING:
 Repositioning of the patient to off load areas of high pressure is an
important component of PU prevention.
 It was suggested that the patient be turned every 2 hours, alternating
from lateral to a supine position regularly to minimize the shear and
friction forces on the skin.
 When turned to side, patient should be rotated 30 degree lateral
position to prevent pressure on the trochanter.
 Pillows or blankets should be used to pad areas that may touch such
as between the knees
 Rotate positioning on the right side, back, left side.

21. CONT..

22. 3. SUPPORT SURFACES:
 These are special cushions, pads, overlays, mattresses and
integrated bed systems that relieve pressure on an existing sore
and help protect vulnerable areas from further breakdown.
 They offer redistribution of pressure and are designed to alternate
the patients body area in contact with the support surface and to
reduce interface pressure e.g. low air flow mattresses, pressure
redistributing mattresses.

23. CONT..

24. 4. PREVENTIVE SKIN CARE:
 It is of utmost importance to keep the skin clean and dry and
applying moisturizers on dry skin and barrier products on skin
exposed to excessive moisture.
 Barrier creams form a protective layer that keeps away excessive
moisture from incontinence, sweat, or wound drainage and aids in
maintaining skin integrity.
 Powder should not be used

25. 5. APPLICATION OF SKIN PROTECTIVE DRESSINGS:
 Hydrocolloid dressings, have an adhesive compound in
combination with a water resistant outer layer and are normally used
in wound care, are frequently used in combination with barrier
creams to prevent additional moisture exposure.
 Application of silicon foam dressings to anatomical areas frequently
subjected to pressure friction and/or shear (e.g. heels and sacrum)
should be considered.

26.  DRESSING PROTOCOL:
 Check and assess under the dressing at every shift – and document
the findings
 Peel dressing back, assess and re-apply – ensure the border of the
dressing is smooth with no wrinkles
 Document on the SSKIN bundle
(Surface, Skin, Keep moving, Incontinence, Nutrition)
 Remove and replace dressing after 3 days or when necessary
 Replace dressing if the patient is still at risk

27. 6. HYPERBARIC OXYGEN THERAPY:
 Hyperbaric oxygen was also used topically to treat pressure sores
and skin ulcers.
 Specially constructed devices equipped with controlled pressure and
automatic relief valves
 Suppressed bacterial growth, enhanced granulation and epithelium
formation.

28. 7. CLEANING & DEBRIDEMENT:
 It's essential to keep wounds clean to prevent infection.
 A stage I wound can be gently washed with water and mild soap, but
open sores should be cleansed preferably with normal saline, not
with antiseptic agents, ( e.g. povidone iodine).
 Debridement required only in stage ¾ with necrotic tissues followed
by cleaning of wound and application of moist to absorbent dressing.
 Apart from these, skin grafts, bioengineered skin, incision and
drainage

29. ROLE OF NURSE IN PREVENTION & MANAGEMENT OF BED
SORES
 The nurse should be continuingly assessing the patient who are at risk
for pressure ulcer development
Assess the patient for:
 The predisposing factors for bed sore Development.
 Skin condition at least twice a day.
 Inspect each pressure sites.
 Palpate the skin for increased warmth.

30. ROLE OF NURSE…..
 Inspect for dry skin, moist skin, breaks in skin
 Evaluate level of mobility.
 Evaluate circulatory status (eg. Peripheral pulses, edema).
 Determine presence of incontinence
 Evaluate nutritional and hydration status.
 Note present health problems.

31. ROLE OF NURSE…..
Interventions for a patient with decreased sensory perception
 Assess pressure points for signs of bed sore development.
 Provide pressure-redistribution surface.
Interventions for a patient with incontinence
 Following each incontinent episode, clean area and dry thoroughly.
 Protect skin with moisture-barrier ointment.

32. ROLE OF NURSE…..
Interventions to avoid friction and shear
 Reposition patient using draw sheet and lifting off surface.
 Use proper positioning technique & avoid dragging the patient in bed
Interventions for a patient with decreased activity/ mobility
 Establish individualized turning schedule.
 Change position at least once in two hours and more frequently for the
high risk individuals.

33. ROLE OF NURSE…..
Interventions for a patient with Poor nutrition
 Provide adequate nutrition and fluid
 Assist with intake as necessary.
 Consult dietitian for nutritional evaluation
Other interventions
 Evaluate the ulcer progress every 4-6 days.
 Assist the physician or surgeon in debridement
 Educate the patient and family regarding the risk factors and prevention of
bed sores.
Bedsores are easier to prevent than to
treat

36.  Out of the multiple tools like Braden scale, Cubbin and Jackson scale,
Norton scale, and Waterlow scale, the Braden scale is one of the most
commonly used tool.
 It is a summated rating scale that is made up of six subscales for a total
score that ranges from 6-23.
 A lower Braden scale score indicates a higher risk for PU development.
 ICU patients are usually categorized into four PU risk groups depending
on the Braden score as follows:
 Low risk: >18
 At risk : 15-18
 Moderate risk : 13-14
 High risk : 10-12
 Very high risk : <9

37. A bed sore can develop in
as early as two to three
hours. In its early stage,
it usually appears as red
blotch on the skin which
is warm to touch...”
(Johnson & Johnson et
al)
A
Braden Scale for Predicting Pressure Ulcer Risk
Six Criteria:
• Sensory Perception
• Moisture
• Activity
• Mobility
• Nutrition
• Friction and Shear