amna
03/03/04, 07 :18 07:18:15 PM
PRESSURE SORES
Easy to avoid difficult to manage
DEFINITION:
v BED SORES ARE LOCALIZED ULCERATION OF THE SKIN OR DEEPER STRUCTURES.
v THEY MOST COMMONLY RESULT FROM PROLONGED PERIODS OF BED REST IN ACUTE OR LONGTERM CARE FACILITES.
THE AREAS SUSCEPTIBLE TO PRESSURE SORES:
1. OCCIPUT
2. EAR
3. SCAPULA
4. ELBOW
5. SACRUM
6. ISCHIAL TUBEROSITIES
7. GREATER TO CHANTER
8. MEDIAL CONDYLE OF TIBIA
9. FIBULAR HEAD
10. MEDIAL MALLEOLUS
11. LATERAL MALLEOLUS
12. HEAL
PATHOPHYSIOLOGY & ETIOLOGY:
1. PRESSURE OF (70mmHg) APPLIED FOR LONGER THAN 2HOURS CAN PRODUCE TISSUE, DESTRUCTION HEALING CON NOT ACCUR WITH OUT RELIVING THE PRESSURE.
2. FRICTION CONTRIBUTES TO PRESSURE SORES DEVELOPMENT BY CAUSING ABRASION OF THE STRAUM CORNCUM.
3. SHEARING FORCE PRODUCED BY SLIDING OF ADJACENT SURFACES, IS PARTICULARLY IMPORTANT IN THE PARTIAL SITTING POSITION. THIS FORCE RUPTURES CAPILLARIES OVER THE SACRUM.
4. MOISTURE ON THE SKIN RESULTS IN MACERATION OF THE EPITHELIUM.
RISK FACTORS FOR PRESSURE SORES: PATIENT CONDATION
1. BOWEL OR BLADDER INCONTINENCE.
2. MALNOURISHMENT OR SIGNIFICANT WEIGHT LOSS.
3. EDEMA,ANEMIA,HYPOXIA, HYPOTENSION.
4. NEUROLOGIC IMPAIRMENT OR IMMOBILITY.
5. ALTERED MENTAL STATUS,INCLUDING DELIRIUM OR DEMENTIA.
NURSING ASSESSMENT:
1. ASSESS FOR RISK FACTORS FOR PRESSURE SORE DEVELOMENT AND ALTER THOSE ,IF POSSIBLE.
2. ASSESS SKIN OF OLDER ADULT FREQQUENTLY FOR THE DEVELOPMENT OF PRESSURE SORES.
3. STAGE THE ULCER SO APPORPRIATE TREATMENT CAN BE STARTED.
4. ONE COMMONLY USED STAGING SYSTEM ADVISORY PANEL INCLUDES( 4 ) LEVELS:
a-NONBLANCHINGMACULE THAT MAY APPEAR RED OR VIOLET.
b-SKIN BREAK DOWN AS FAR AS THE DERMIS.
c- SKIN BREAK DOWN INTO THE SUBCUTANEOUS TISSUE.
d-PENETRATES BONE,MUSCLE,OR JOINT.
NURSING AND PATIENT CARE CONSIDERATIONS:
v PREVENT PRESSURE SORE DEVELOPMENT.
1) PROVIDE METICULOUS CARE AND POSITING FOR IMMOBILIZED PATIENTS.
a. INSPECT SKIN SEVERAL TIMES DAILY.
b. WASH SKIN WITH MILD SOAP,RINSE,AND BLOT DRY WITH A SOFT TOWEHL.
c. LUBRICATE SKIN WITH A BLAND LOTION TO KEEP SKIN SOFT AND PLIABLE.
d. AVIOD POORLY VENTILATED MATTRESS THAT IS COVERED WITH PLASTIC OR IMERMEABLE MATERIAL.
e. EMPLOY BOWEL AND BLADDER PROGRAMS TO PREVENT INCONTINENCE.
f. ENCOURAGE AMBULATION AND EXERCISE.
g. PROMOTE NUTRITION DITE WITH OPTIMAL PROTEIN,VITAMINS,AND IRON.
2) TEACH OLDER ADULT AND FAMILY OR SIGIFICANT OTHER THE IMPROTANCE OF GOOD NUTRITION,HYDATION,ACTIVITY POSITIONING ,AND AVOIDANCE OF PRESSURE,SHEARING,FRICTION,AND MOISTURE.
v RELEVE THE PRESSURE.
1) AVIOD ELEVATION OF HEAD OF BED GREATER THAN 30 DEGREES.
2) REPOSITION EVERY 2 HOURS.
3) USE SPECIAL DEVICES TO CUSHING SPECIFIC AREAS,SUCH AS FLOTATION RINGS,LAMBS WOOL OR FLEECE PAD ,EGG-CRATE MATRESSES,BOOTIES,ELBOW PADS.
4) UES AN ALTERNATING-PRESSURE MATTRESS OR AIR FLUIDIZED BED FOR PATIENTS AS HIGH RISK TO PREVENT OR TREAT PRESSURE SORES.
5) PROVIDE FOR ACTIVTY AND AMBULATION AS MUCH AS POSSIBLE.
6) ADVISE FREQUENT SHIFTING OF WIGHT AND OCCASIONAL RAISING OF BOTTOM OFF CHAIR WHILE SITTING.
v CLEAN AND DEBRIDE THE WOUND.
1) USE NORMAL SALINE FOR CLEANING AND DISINFECTING WOUNDS.
2) APPLY WET-TO-DRY DRESSINGS OR ENZYME ONITMENTS FOR DEBRIDEMENT AS DIRECTED ;OR ASSIST WITH SURGICAL DEBRIDEMENT.
v TREAT LOCAL INFECTION.
1) OPEN WOUND ARE ALWAYS COLONIZED WITH BACTERIA ;HENCE ,WOUND CULTURES ARE UNNECESSARY UNLESS THERE IS EVIDENCE OF SYSTEMIC INFECTION OR PROGRESSIVE LOCAL INFECTION SUCH AS CELLULITIS.
2) APPLY TOPICAL ANTIBIOTICS TO LOCALLY INFECTED PRESSURE ULCER AS PRESCRIBED.
v COVER THE WOUND WITH A PROTECTIVE DRESSING.
1) THIS MINIMIZES DISRUPTION OF MIGRATING FIROBLASTS AND EPITHELIED CELLS AND RESULTS IN MOIST ,NUTRIENT-RICH ENVIROMENT FOR HEALING TO OCCOU:
a) POLYURETHANE THIN FILM DRESSING CAN BE USED FOR SUPERFICIAL LOW-EXUDATE WOUND ,THEY ARE AIR AND WATER PERMEABLE BUT DO NOT ABSORD EXDATE.
b) HYDROCOLLOIDS CAN PROVIDE PADDING TO WOUND BUT CAN LEAD TO MACERATION;THEY ARE NOT OXYGEN PERMEABLE.
c) POLYURETHANE FOAM/MEMBRANCE DRESSING ABSORB EXDATE AND ARE OXYGEN PERMEABLE.
d) HYDROGEL DRESSING ARE MULTILAYERED AND INCLUDE PROPERTIES OF BOTH HYDROCOLLOIDS AND POLYURETHANE.
PRESSURE SORES PRESSURE SORES PRESSURE SORES
Easy to avoid difficult to manage
DEFINITION:
v BED SORES ARE LOCALIZED ULCERATION OF THE SKIN OR DEEPER STRUCTURES.
v THEY MOST COMMONLY RESULT FROM PROLONGED PERIODS OF BED REST IN ACUTE OR LONGTERM CARE FACILITES.
THE AREAS SUSCEPTIBLE TO PRESSURE SORES:
1. OCCIPUT
2. EAR
3. SCAPULA
4. ELBOW
5. SACRUM
6. ISCHIAL TUBEROSITIES
7. GREATER TO CHANTER
8. MEDIAL CONDYLE OF TIBIA
9. FIBULAR HEAD
10. MEDIAL MALLEOLUS
11. LATERAL MALLEOLUS
12. HEAL
PATHOPHYSIOLOGY & ETIOLOGY:
1. PRESSURE OF (70mmHg) APPLIED FOR LONGER THAN 2HOURS CAN PRODUCE TISSUE, DESTRUCTION HEALING CON NOT ACCUR WITH OUT RELIVING THE PRESSURE.
2. FRICTION CONTRIBUTES TO PRESSURE SORES DEVELOPMENT BY CAUSING ABRASION OF THE STRAUM CORNCUM.
3. SHEARING FORCE PRODUCED BY SLIDING OF ADJACENT SURFACES, IS PARTICULARLY IMPORTANT IN THE PARTIAL SITTING POSITION. THIS FORCE RUPTURES CAPILLARIES OVER THE SACRUM.
4. MOISTURE ON THE SKIN RESULTS IN MACERATION OF THE EPITHELIUM.
RISK FACTORS FOR PRESSURE SORES: PATIENT CONDATION
1. BOWEL OR BLADDER INCONTINENCE.
2. MALNOURISHMENT OR SIGNIFICANT WEIGHT LOSS.
3. EDEMA,ANEMIA,HYPOXIA, HYPOTENSION.
4. NEUROLOGIC IMPAIRMENT OR IMMOBILITY.
5. ALTERED MENTAL STATUS,INCLUDING DELIRIUM OR DEMENTIA.
NURSING ASSESSMENT:
1. ASSESS FOR RISK FACTORS FOR PRESSURE SORE DEVELOMENT AND ALTER THOSE ,IF POSSIBLE.
2. ASSESS SKIN OF OLDER ADULT FREQQUENTLY FOR THE DEVELOPMENT OF PRESSURE SORES.
3. STAGE THE ULCER SO APPORPRIATE TREATMENT CAN BE STARTED.
4. ONE COMMONLY USED STAGING SYSTEM ADVISORY PANEL INCLUDES( 4 ) LEVELS:
a-NONBLANCHINGMACULE THAT MAY APPEAR RED OR VIOLET.
b-SKIN BREAK DOWN AS FAR AS THE DERMIS.
c- SKIN BREAK DOWN INTO THE SUBCUTANEOUS TISSUE.
d-PENETRATES BONE,MUSCLE,OR JOINT.
NURSING AND PATIENT CARE CONSIDERATIONS:
v PREVENT PRESSURE SORE DEVELOPMENT.
1) PROVIDE METICULOUS CARE AND POSITING FOR IMMOBILIZED PATIENTS.
a. INSPECT SKIN SEVERAL TIMES DAILY.
b. WASH SKIN WITH MILD SOAP,RINSE,AND BLOT DRY WITH A SOFT TOWEHL.
c. LUBRICATE SKIN WITH A BLAND LOTION TO KEEP SKIN SOFT AND PLIABLE.
d. AVIOD POORLY VENTILATED MATTRESS THAT IS COVERED WITH PLASTIC OR IMERMEABLE MATERIAL.
e. EMPLOY BOWEL AND BLADDER PROGRAMS TO PREVENT INCONTINENCE.
f. ENCOURAGE AMBULATION AND EXERCISE.
g. PROMOTE NUTRITION DITE WITH OPTIMAL PROTEIN,VITAMINS,AND IRON.
2) TEACH OLDER ADULT AND FAMILY OR SIGIFICANT OTHER THE IMPROTANCE OF GOOD NUTRITION,HYDATION,ACTIVITY POSITIONING ,AND AVOIDANCE OF PRESSURE,SHEARING,FRICTION,AND MOISTURE.
v RELEVE THE PRESSURE.
1) AVIOD ELEVATION OF HEAD OF BED GREATER THAN 30 DEGREES.
2) REPOSITION EVERY 2 HOURS.
3) USE SPECIAL DEVICES TO CUSHING SPECIFIC AREAS,SUCH AS FLOTATION RINGS,LAMBS WOOL OR FLEECE PAD ,EGG-CRATE MATRESSES,BOOTIES,ELBOW PADS.
4) UES AN ALTERNATING-PRESSURE MATTRESS OR AIR FLUIDIZED BED FOR PATIENTS AS HIGH RISK TO PREVENT OR TREAT PRESSURE SORES.
5) PROVIDE FOR ACTIVTY AND AMBULATION AS MUCH AS POSSIBLE.
6) ADVISE FREQUENT SHIFTING OF WIGHT AND OCCASIONAL RAISING OF BOTTOM OFF CHAIR WHILE SITTING.
v CLEAN AND DEBRIDE THE WOUND.
1) USE NORMAL SALINE FOR CLEANING AND DISINFECTING WOUNDS.
2) APPLY WET-TO-DRY DRESSINGS OR ENZYME ONITMENTS FOR DEBRIDEMENT AS DIRECTED ;OR ASSIST WITH SURGICAL DEBRIDEMENT.
v TREAT LOCAL INFECTION.
1) OPEN WOUND ARE ALWAYS COLONIZED WITH BACTERIA ;HENCE ,WOUND CULTURES ARE UNNECESSARY UNLESS THERE IS EVIDENCE OF SYSTEMIC INFECTION OR PROGRESSIVE LOCAL INFECTION SUCH AS CELLULITIS.
2) APPLY TOPICAL ANTIBIOTICS TO LOCALLY INFECTED PRESSURE ULCER AS PRESCRIBED.
v COVER THE WOUND WITH A PROTECTIVE DRESSING.
1) THIS MINIMIZES DISRUPTION OF MIGRATING FIROBLASTS AND EPITHELIED CELLS AND RESULTS IN MOIST ,NUTRIENT-RICH ENVIROMENT FOR HEALING TO OCCOU:
a) POLYURETHANE THIN FILM DRESSING CAN BE USED FOR SUPERFICIAL LOW-EXUDATE WOUND ,THEY ARE AIR AND WATER PERMEABLE BUT DO NOT ABSORD EXDATE.
b) HYDROCOLLOIDS CAN PROVIDE PADDING TO WOUND BUT CAN LEAD TO MACERATION;THEY ARE NOT OXYGEN PERMEABLE.
c) POLYURETHANE FOAM/MEMBRANCE DRESSING ABSORB EXDATE AND ARE OXYGEN PERMEABLE.
d) HYDROGEL DRESSING ARE MULTILAYERED AND INCLUDE PROPERTIES OF BOTH HYDROCOLLOIDS AND POLYURETHANE.
PRESSURE SORES PRESSURE SORES PRESSURE SORES