Halime Aydın, Bengüsu Öroğlu, Gülcan Kar, Mustafa Öncel PRESSURE WOUND MD. LÜTFİ KIRDAR KARTAL EDUCATION AND RESEARCH HOSPITAL STOMATOTHERAPY UNIT

PRESSURE WOUND Pressure wound is lokalized tissue damage that usually occurs skin on bones and subcutaneous tissues via pressure or friction and rupture with pressure. (NPUAP, 2007)

The most cheapest and easy way to prevent pressure wound is applications of preventer nurse procedures. However wounds with different grades occur because of various reasons. It is aimed that quick recovery with good nursing and wound care. PRESSURE WOUND

Patiens having pressure wounds are usually older than 70 age and have 8% mortality risk. (Oguz,1998) Risk factors that induce pressure wonds without old age;  Neurological diseases,  Malnutrition,  Chronic diseases,  Physical inactivity.

CASE Woman H.A., 85 age, mother of 5 children. Blind for 40 years. Urinar and fecal incontinence for 2-3 years.

She was hospitalized for general stiuation disorder at 29 September It was observed that she had not any chronic disease as a result of investigations (hypertension, diabetes etc.).

HOWEVER…. It was confirm that extreme malnutrition. It was found that pressure wounds more than one. (Sacral, torachanter and heel area)

EVALUATION RISK OF PRESSURE WOUND FORMING WITH BRADEN SCALE EMOTIONAL SENSE 1-COMPLETELY LIMITED 2-MOSTLY LIMITED 3-SLIGHTLY LIMITED 4-NO DAMAGE MOISTURE/WET1-ALWAYS WET2-FREQUENTLY WET 3-SOMETIMES WET 4-RARELY WET ACTIVITY1-LIVE BEDRIDDEN2-SIT CHAIR 3-SOMETIMES WALK 4-WALK MOTION 1-COMPLETELY INACTIVE 2-VERY LIMITED 3-SLIGHTLY LIMITED 4-NO LIMITED (ACTIVE) NUTRITION 1-UNSUFFICIENT (CACHECTIC) 2- PARTIALLY ENOUGH 3-ENOUGH4-VERY GOOD FRICTION AND RUPTURE 1-PROBLEM2- MAY BE PROBLEM3- NO PROBLEM *19–23: NO RİSK *15–18: RISK ON THE EDGE *13–14: MEDIUM RISK *0–12:HIGH RISK *9 AND LOWER: VERY HIGH RISK *RISK OF PRESSURE WOUND FORMING IS 15–18 AND LOWER LOOK AT THE GUIDE OF NURSING PLAN FOR DAILY ACTIVITIES. PUAN TOPLA

CASE SACRAL AREA PHASE III VE PHASE IV

SACRAL AREA: 22x15x5 cm 29Eylül2009

Torachanter 10x7x7 cm Suspicious subcutaneous lesion

HEEL Suspicion of deep tissue damage

HELL 5X5 CM PHASE II-III

NURSING PLAN Change position of patient to reduce pressure every 2 hours, Provide using of support materials to reduce pressure, Clean and dry skin, Clean and creaseless sheet, Organize nurition and fluid intake, Provide adaptation of patient’s relative to nursing plan via training.

It was gave that suitable position to the patient and changed every 2 hours. It was provided that enough fluid intake and organized nutrition (eternal nutrition). Skin care was done. The family was trained for this subjects. NURSING

Healty tissue around the wound was cleaned with batticon. İnternal wound was washed with normal saline. Necrotic tissues were removed with surgical debridement. SACRAL AREA: 22x15x5 cm WOUND CARE STEP BY STEP

AFTER 2 WEEKS 20x14x5  Infected, smelly internal wound was washed with normal saline and silver wound dressing was applied.  Cavity spaces were filled with this silver woud dressing.  Barrier cream was used to protect wound around.  The area with rich exudate was covered with NEODERM ®. AŞAMA AŞAMA YARA BAKIMI

 AFTER 6 MONTHS 13X7X2 cm

AFTER 4 MONTHS 8X4X  Wound was cleaned completely and there was no necrotic area.  This stage, Neoderm® was applied again.

FIRST LATER

 Skin was cleaned and mL, infected, smelly and sludgy exudate was drained via opening necrotic area with surgical incision.  Internal wound was washed with isotonic solution for several times and wound space was filled with silver wound dressing. AŞAMA AŞAMA YARA BAKIMI TORACHANTER AREA SUSPICION OF DEEP TISSUE DAMAGE

TORACHANTER AREA  Barrier cream was applied to around tissues.  Wound area with rich exudate was covered with Neoderm®.  At first, dressing was done day to day. After that, changing time was extended because of decreasing exudate OPEN WOUND AŞAMA AŞAMA YARA BAKIMI AFTER OPENING TORACHANTER AREA 10x7x7 cm

AFTER 6 WEEKS

AFTER 8 WEEKS 6X4x3 cm

 AFTER 4 MONTHS 3X3X3cm

AFTER 5 MONTHS 1X1.5X0.5 cm

FIRST LATER

HEEL 5X5 cm

AFTER 6 WEEKS

AFTER 4 MONTHSAFTER 2 MONTHS

NEODERM ® APPLICATION

AFTER 5 MONTHS 2X2X1cm

FIRST LATER

RESULT Pressure wounds can be treated applying well organized nursing, And doing effective and organized wound care.

WITH HER GRANDCHILD CANSU

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