1. Chapter 25
Pressure Ulcers

2. Patient-Centered Care
Discuss pressure ulcer risk factors with patient and family.
Identify individual factors that influence wounds:
Nutrition, infection, oxygenation, circulation, age, medications, stress
Individualize assessment techniques for patients with dark skin.
Maintain patient privacy during assessment and wound care.

3. Patient-Centered Care
Discuss pressure ulcer risk factors with patient and family.
Identify individual factors that influence wounds:
Nutrition, infection, oxygenation, circulation, age, medications, stress
Individualize assessment techniques for patients with dark skin.
Maintain patient privacy during assessment and wound care.

4. Patient-Centered Care
Discuss pressure ulcer risk factors with patient and family.
Identify individual factors that influence wounds:
Nutrition, infection, oxygenation, circulation, age, medications, stress
Individualize assessment techniques for patients with dark skin.
Maintain patient privacy during assessment and wound care.

5. Procedural Guideline 25.1 Selection of Pressure-Reducing Surfaces
Pressure ulcers can occur in any setting, including the operating room.
Observer skin for signs of injury or breakdown.
Instruct ambulatory surgery patients to monitor their skin.

6. Procedural Guideline 25.1 Selection of Pressure-Reducing Surfaces (cont’d)
Use specialized support surfaces.
Nonpowered surfaces
Foam, air, gel mattresses, beds, or cushions
Powered surfaces
Change pressure beneath patient.
Provide slick surface to reduce friction and shear.
Allow airflow to reduce moisture.

7. Procedural Guideline 25.1 Selection of Pressure-Reducing Surfaces
Pressure ulcers can occur in any setting, including the operating room.
Observer skin for signs of injury or breakdown.
Instruct ambulatory surgery patients to monitor their skin.

8. Skill 25.1 Pressure Ulcer Risk Assessment and Prevention Strategies
Use an agency-approved risk assessment tool.
Assess skin on admission and periodically:
Bony prominences
Other potential pressure areas
Skin next to treatment and assistive devices
Assess intact, darkly pigmented skin.
Use natural or halogen lighting.
Assess for changes in localized color, tissue consistency, sensation, or skin temperature.

9. Staging Pressure Ulcers
A, Stage I. B, Stage II. 9

10. Staging Pressure Ulcers (cont’d)
C, Stage III. D, Stage IV.

11. Skill 25.2 Treatment of Pressure Ulcers and Wound Management
Reduce or eliminate the cause.
Create an environment conducive to healing.
Treat per physician or wound specialist orders.
Assess and document wound characteristics.
Cleanse with prescribed solution from least to most contaminated area.
Apply topical agent if ordered.
Apply prescribed dressing per instructions.
Cover with secondary dressing if indicated.

12. Staging Pressure Ulcers (cont’d)
C, Stage III. D, Stage IV.

13. Traction, Cast Care, and Immobilization Devices
Chapter 17
Traction, Cast Care, and Immobilization Devices

14. Patient-Centered Care
Musculoskeletal trauma, disease, or surgery requires immobilization, stabilization, and support to promote healing.
Provide pain relief measures while devices are in use.
Educate patients to minimize anxiety.
Provide information specific to device in use.
Be aware of cultural considerations.
Provide privacy and modesty during procedures.

15. Safety
Prevent skin and nerve damage monitoring all immobilization and stabilization devices.
Monitor skin and underlying tissues for signs of pressure.
Compare affected extremity with unaffected side.
Assess the five Ps of neurovascular function.
Assess and alert the health care provider for:
Cool, pale skin.
Diminished pulses.
Prolonged capillary refill.
Pain, numbness, and tingling.

16. Assessment of Neurovascular Function (The Five P’s)
Pain
Pallor
Paralysis
Paresthesia
Pulselessness

17. Skill 17.1 Care of the Patient in Skin Traction
Skin traction indirectly immobilizes fractures.
Relieves muscle spasm and pain
May be temporary until surgical repair occurs
Monitor:
Musculoskeletal alignment.
Maintenance of the traction device using four Ps:
Pounds—Correct weight, hanging freely
Pressure—Clamps and connections tight
Pull—Alignment of pull direction with long axis of bone
Pulleys—Smoothly gliding ropes

18. Skill 17.2 Care of the Patient in Skeletal Traction and Pin Site Care
Skeletal traction uses pins to immobilize fractures and promote bone repair.
External fixation promotes early ambulation and use of other joints.
Provide:
Pin site care to reduce risk of infection.
Routine monitoring of traction and affected area for proper alignment and skin integrity.
Pharmacological and nonpharmacological pain relief.
Active and passive exercises of unaffected extremity.

19. Skill 17.3 Care of the Patient During Cast Application
Casts immobilize and protect injured extremities
Casts provide alignment, and promote comfort.
Educate patient on cast care and symptoms to report.
Monitor for five Ps.

20. Skill 17.3 Care of the Patient During Cast Application (cont’d)
Cast materials depend on area of injury.
Plaster of Paris
Requires 24 to 72 hours to dry
Must be handled carefully to protect underlying tissues
Weighs more than synthetic cast
Synthetic
Sets quickly
Radiolucent
Lightweight and waterproof

21. Procedural Guideline 17.1 Care of the Patient During Cast Removal
Casts are removed with a vibrating saw.
Educate patients about sensations they might feel during removal of the cast.
Vibration, heat
Remove padding or lining carefully.
Inspect skin and underlying tissues.
Gently cleanse and dry skin and apply lotion.
Provide instruction to patient/family regarding skin care, reduction of edema, and pain control.

22. Skill 17.4 Care of the Patient with an Immobilization Device
Immobilization devices increase stability, support weak extremities, reduce weight-bearing load, and protect body parts.
Splints may provide long- or short-term therapy.
Used for fractures, sprains, or after surgery
Maintain body parts in functional position to prevent contractures and muscle atrophy during disuse
May be used to assist weight-bearing and ambulation
Educate on splint care and symptoms to report.
Monitor for five Ps.