1.To create an environment that allows soft tissue viability and promotes healing of pressure ulcer.
The term tissue load refers to the distribution of pressure, friction, and shear on tissue.
2. Avoid assuming of patients on pressure ulcers. Assess it ,measure it and take pictures. Evaluation and treatment.
3.Limit the amount of time that the head of bed is elevated.
4. The shear forces generated when an individual slides down in bed contributes to Ischemic wound and necrosis of sacral tissue and undermining of existing sacral ulcers.
5.Static support surfaces: Use a static support surface if a patient can assume a variety of positions without bearing weight on a pressure ulcer and without bottoming out.
6. If the caregiver feels less than an inch of support material and support materials are inadequate patient will button out.
7.If a patient has large stage 111 or stage IV pressure ulcers on multiple turning surfaces, a low air bed or an air- fluidize bed may be indicated. A low -air- loss bed may also be indicated if the individual button out or fails to heal on a dynamic overlay or mattress.
8. Excess moisture on intact skin is a potential source of maceration and skin breakdown.
9. Sitting position: Patient should be taught to shift their weight every 15minutes.
10.Initial care of pressure ulcer involves debridement, wound cleansing. Application of dressings and possibly adjunctive therapy- operative repair in some cases.
11.When debriding extensive stage IV pressure ulcers in the operating room the surgeon should consider a bone biopsy to detect Osteomyelitis. 12.Autolytic debridement involves the use of synthetic dressing to cover a wound and allow devitalized tissues to self digest from enzymes normally present in the wound fluids.
This technique should not be used if the wound is infected.
Nurses You Move Me 