1. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 19 Preventing Pressure Ulcers and Assisting With Wound Care

2. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Preventing Pressure Ulcers and Assisting With Wound Care

3. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Pressure ulcers, also known as decubitus ulcers or bed sores, form when pressure points press against any surface. Pressure Ulcers

4. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Pressure Ulcers (cont.)

5. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Pressure Points Pressure points are bony areas, such as heels, ankles, knees, hips, toes, elbows, shoulder blades, ears, the back of the head, and along the spine, where pressure ulcers are likely to form.

6. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Pressure Points (cont.)

7. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Pressure ulcers form when: –Pressure points press against any surface for a long period of time. –Pressure squeezes the tissues between the bone and the surface the person is lying or sitting on. –Blood flow to the tissues decreases. –Tissues die because of lack of nutrients and oxygen. –Necrotic or dead tissue peels off or breaks open, creating an open sore or ulcer. Pressure Ulcers

8. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Risk factors for developing a pressure ulcer include: –Limited mobility –Fragile skin with less blood flow because of aging –Poor nutrition and lack of fluids –Prolonged contact with moisture –Cardiovascular or respiratory problems –Friction and shearing injuries Pressure Ulcers (cont.)

9. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Omnibus Budget Reconciliation Act Long-term care facilities are evaluated by their team’s ability to prevent residents from getting pressure ulcers. The nurse is responsible for: –Assessing each resident’s risk of developing pressure ulcers –Documenting any existing pressure ulcers –Carefully following each resident’s care plan

10. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Stages of Pressure Ulcers A reddened area of skin appears; it does not return to the normal color after the pressure is removed. The pressure ulcer looks like a blister, an abrasion, or a shallow crater. The epidermis and dermis are gone, subcutaneous fat may be visible, and there may be drainage from the wound. The crater of damaged tissue extends from the tissues to the muscle or bone.

11. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Prevention of Pressure Ulcers Pressure ulcers are: –Painful –Hard to treat –Potentially fatal Every effort must be made to prevent a pressure ulcer from forming.

12. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Interventions to Prevent Pressure Ulcers Regularly reposition patients who are restricted to a bed or wheelchair. Observe patients’ skin for changes at every opportunity. Frequently check on incontinent patients and residents. Provide good skin and perineal care. Encourage patients or residents to take a walk with you every 2 hours.

13. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Interventions to Prevent Pressure Ulcers (cont.) Make sure the bed linens are clean, dry, and wrinkle- free at all times. Provide frequent back massages. Minimize skin injury caused by friction or shearing. Encourage your patients and residents to eat well. Use pressure-reducing devices according to the person’s care plan.

14. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Special equipment that may be used to help prevent formation of pressure ulcers includes: –Elbow pads and heel booties –Bed cradle –Footboard –Bed board –Pressure-relieving mattress –Special beds Pressure-Reducing Devices

15. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Wounds A wound is an injury that results in a break in the skin. A pressure ulcer is a type of wound. An intentional wound is a result of planned surgical or medical intervention. An unintentional wound is an unexpected injury that usually results from some type of trauma or violence.

16. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Wound Healing A wound creates an opening that allows microbes to enter the body. Several factors can delay healing: –Multiple injuries –Chronic illness –A weakened immune system –Very young or very old age –Poor nutrition

17. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Fluid that is allowed to collect in a wound can delay the healing process. Wound drains may be used to remove fluids from the wound. When repositioning a person with a drain, take care not to pull on the drain tubing. Wound Drains

18. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Wound Drains (cont.)

19. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Dressings are applied to: –Prevent microbes from gaining access to the body –Keep the wound dry –Absorb drainage from the wound Wound Dressings

20. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Wound Dressings (cont’d)

21. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Securing Wound Dressings The type of tape used to secure dressings depends on: –The location of the wound –The needs of the person Montgomery ties: –Are used for wounds that drain heavily –Help protect skin from damage caused by frequent removal and reapplication of tape

22. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Securing Wound Dressings (cont.)