Pressure ulcer in a simple term is known as bedsores or decubitous ulcers.
They are localized damages to the skin.They are very expensive to treat,
so the best thing is not to develop pressure ulcer.The hallmark sign of pressure
ulcer is that they usually develop over Bony Prominence due to unrelieved pressure
such as the back of the head,sacrum,coccyx,hips,ankles,elbows, occipital,shoulder,
ischium,ilac crest,medial malleolus,lateral malleolus etc.Development of pressure
ulcer around the ears is due to equipment.
Pressure ulcer could be a combination of pressure and friction.
If you are alert and oriented x4,walking,able to comprehend,not incontinent.
Will you develop pressure ulcer?The answer is “NO”.
So if you are compromised,you stayed in bed for too long or in one position
for too long.And you are not able to repostion yourself because
you are bed ridden or wheelchair bound.Then pressure ulcer will develop.
due to unrelieved pressure.
When there is a limitation in the flow of blood in the area where there is pressure
bedsore will develop. Pressure ulcer or bedsore is categorized in stages.
You cannot talk about pressure ulcer without understanding the BRADEN SCALES.
Please look up on Braden scales.It is a scale for predicting pressure ulcer risks.
And understanding who are at risk for developing pressure ulcer.
The Braden Scales for Pressure ulcer is as follows:
Lowest risk 15-18
Moderate risk 13-14.
High risk 10-12
Highest risk 9.9 and below.
When you think about Braden Scales think about the following.
Is the patient able to respond to pressure?.
To what degree is the skin expose to moisture?
Is the patient active?
What about their nutritional intake?
Can patient reposition self in bed or can patient ambulate(That is walk).
How to prevent Pressure Ulcer:
To prevent pressure ulcer is to understand the skin,nutritional intake, the Braden scales,
immobility,various types of wound including their origin, wound care.
These are very important as an healthcare professional.
The right equipment should be in place for bariatric patients.
According to the National Center for Health Statistics report shows that 30% of
American adults are obese-over six million Americans.
Reposition patient every two hours while in bed,and evry one hour while in the wheelchair.
(PT/OT ) Physical and Occupation therapists should be ordered for all patients.
Physical therapist should evaluate who need therapy and who need treatment.
Physical and occupational theraist clearance sould be done before discharge
home or SNF or REHAB transfer.Each patient situation is different.
Nurses should encourage and assist in early ambulation and other activities
of their patients.
Nurses are to medicate patients for pain thirty minutes prior to physical activities.
Unnecessary immobility should be discouraged by the nurses.
The GOLD STANDARD will be getting the patient ready for physical activities as
long as it is NOT against doctor orders.
Is there an OVERHEAD TRAPEZE for the patient to turn and
reposition self while in bed?
Avoid Electrical blanket under an immobilized patient with very low Braden Scales.
During repositioning ,watch out for bony prominent areas.Protect bony prominent areas.
NUTRITION:
Nutrition Assessment.
Can the patient eat independently?
Does patient have adequate nutrtion.
Is there a recent weight loss >5% in 30days.
What is the prealbumin level?
WNL > 16 mg/dl
What is Albumin level?
WNL >3.5g/dl
But if the patient is trauma patient,inflammation or has infection.Plasm prealbumin level can be false result since the prealbumin level has been affected due to trauma,or infection or inflammation.Then the C-reactive protein test can be use instead.It is the doctor decision if he/she wants to do that.
The importance of adequate nutrition cannot be overemphasized.
Evaluate PO intake that is can the patient tolerate food by mouth very well ?.
Eating 80-100%. Is patient getting enough nutrient?
If NO can the patient swallow?
Does patient need swallow evaluation?can your patient chew?
If NO Speech therapist and nutrition consult will be ordered by the doctor.
Speech therapist will evaluate for swallow and make recommendation.
Registered Nutritionist will make recommendation on type of feeding.
Tube feeding type for example Glucerna.1.0,1.5, jevity 1.0 or 1.5,Suplena
based on patient disease process and notify the doctor
on their recommendations.
And the doctor will write the orders.
Does the patient need Tube feeding,TPNor PPN ?
If your patient is not getting adequate nutrion,notify your doctor so that
he or she can order Nutrition Consult.
And the Nurse will execute the orders.
Next concern do the hospital beds have moisture control assistive device?
Is redistribution of pressure and comfort provided for patient?.
Are the patient feet off -loading from the mattress?.
Understanding of the wound that you are dealing with is very important because
successful treatment involves not just the wound but a complete knowledge of the
patient with the wound.
For example who is this patient?
Does the patient have diabetes,vascular disorder,anemia,hypothyroidism,
obese,COPD,or CHF?.
Is he/she a cigarette smoker?
In order words, good assessment of the comorbidities
are very important for adequate wound healing.
HOW DO I HEAL THE WOUND.
Assess location of wound,type of tissues,etiology of the wound,wound
suroundings, amount of exudate,odor,pain, signs and symptoms of infection.
Is the wound viable?
What are the factors affecting the wound?.
(A) Maintain moist environment for the wound to heal.
(B)Keep the wound surrounding clean.
(C)Avoid early closure of the wound that is not ready to be closed.
Why? Because it will be back to SQUARE ONE.
When it becomes clear that the drainage from the wound is winding
down,then the wound is getting ready to be closed.
(D)Excess exudate should be removed.
(E) Understand skin condition,products,products adherence
, and absorption and quality of products when making selection.
(F) Understand various ulcers such venous,arterial ulcer,lymphatic ulcer
and diabetic wounds and the types of dressings.
When do you use a negative pressure wound therapy or
any other type of wound therapy?.What are the indication and special
reasons or rational for using Hyperbaric Oxygen Therapy?.
One simple thing that I will say to you is please assess your
patient,his/her lab values and check the blood sugar.
If the blood sugar is low take action.Follow doctor’s order.
Please Note: “NO DEBRIDEMENT NEEDED ON A DRY
NECROTIC WOUND ON THE FEET”
QUESTIONS:
(1 )Bedridden patient position should be repositioned.While in bed—————————and
while in wheelchair—–———————————–
(2) Partial thickness wound can be classify as:
(a) Stage IV
(b) Stage 111
(c) Stage 11
(d) Stage 1
(3) Full thickness wound without exposed bony areas ,tendonor
slough should be classified as.:
(a) Stage 11
(b) Unstageable.
(c) Stage IV
(D) Stage III
Answers 1.Every two hours and every one hour.
2. C.
3. D.
REFERENCES:
SCOTTSDALE WOUND MANAGEMENT GUIDE.
A comprehensive Guide for the Wound Care Clinician.
2ND EDITION Pages 13 -123.
Black J,Clark M,Dealey C,et al.Dressings as an adjunct to pressure Ulcer prevention:
consensus panel recommendations.Intwoundj.2015;12(4)480 -485.
Washington,DC: National Pressure ulcerAdvisory Panel,2009.
Lippincott William&Wilkins: Wound care Incredibly Visual. 2nd Edition. Pages 3-26.
Diane L. Krasner,PhD,RN,FAAN . Chronic Wound Care.A Clinical Source Book for
Healthcare Professionals. Pages 1-20.
Nurses You Move Me 