Chapter 5 Assisting Clients With Hygiene
Section 6 Prevention and Care of Pressure Ulcers
contents Contributing Factors to Pressure
Ulcers Formation Prediction and Prevention of Pressure
Ulcers Treating and nursing pressure ulcer
Economic consequences of pressure ulcers Frequency:
3-14%,2-25%(nursing home) 85.7% paraplegia 58% pressure ulcer > 65y
Economic consequences: Days in hospital increase Cost of heath care increase: $4,000-40,000
decubitus ulcer, and bedsore Concept: pressure sore,
a localized area of tissue lesion and necrosis that tends to develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period, blood circulation is obstructed, and local tissue is ischemic.
Pressure ulcer
Contributing Factors to Pressure Ulcers Formation Factor of pressure
Pressure Friction Shearing force
Moisture irritation to the Skin Nutritional Status Age Fever (infection) Orthopedic Devices
垂直压力剪切力
摩擦力
Pressure
Shearing
force
Friction
Factor of pressure
Moisture irritation to the Skin
urinary and fecal incontinence wound drainage sweat
Nutritional Status Malnutrition
Protein malnutrition Protein- energy malnutrition
Cachexia Obesity Dehydration Edema
Age Gerontologic nursing practices for the client with
impaired skin integrity★Older adult’s skin is less tolerant to pressure, friction, and
shearing force because of decreased elasticity due to normal aging.
★The older adult has decreased number of sweat glands, leaving the skin dry and less tolerant to shear and friction.
★Impaired skin integrity is a high risk to older adult; it is among the five most common nursing diagnoses for older adult clients in long-term care facilities.
★Dermis of the older adult’s skin is thinner due to the normal absence of subcutaneous fat, therefore making the older adult more susceptible to skin breakdown.
★After the age of 50 epidermal cell renewal reduces by one third, and as a result wound healing is approximately 50% slower than a 35-year-old adult.
★In the presence of chronic coronary or peripheral vascular diseases circulation to the extremities is reduced.
Fever (infection)
increase the body’s metabolic rate increasing the needs of the cells for oxygen Make hypoxemic tissue more susceptible to
ischemic injury diaphoresis
increased skin moisture irritation
Orthopedic Devices plaster, bandage, splint, retractor
reduce mobility of the client or of an extremity
friction pressure
Prediction and Prevention of Pressure Ulcers
Assessment Patients With High Risk of Pressure Ulcers Predicting Pressure Ulcers Risk Common Pressure Ulcer Sites
Preventative interventions
Patients With High Risk of Pressure Ulcers!
Clients with the neural diseases Old people Obesity Debilitated and malnutrition Edema Pain orthopedic devices urinary and fecal incontinence fever quietive therapy
Predicting Pressure Ulcers Risk
predictive instruments the Braden Scale the Norton Scale the Gosnell and Knoll instruments
Items/points 4 3 2 1Activity Mobility Friction and shear Sensory perception Moisture Nutrition
Walks frequently
No limitationsNot at all No impairment Rarely moist Excellent
Walks occasionallySlightly limited
No apparent
problemSlightly limited Occasionally moist
Adequate
Chairfast Very limited Potential problem
Very limited
Very moist Probably inadequate
Bedfast Completely immobile
Problem
Completely limited
Constantly moist
Very poor
the Braden Scale
Items/points 4 3 2 1Mental conditionNutrition conditionMobility Activity Incontinence
Circulation Temperature Medications
Alert
Good
Full
Ambulatory
Absent
Capillary promptly
36.6-37.2℃ Not
Apathetic
Fair
Slightly limitedWalks with helpUrine incontinenceCapillary slowly
37.2-37.7℃ Administering sedatives
Confused
Poor
Very limited
Chair-bound
Fecal incontinenceEdema slightly
37.7-38.3℃ steroidal drugs
Stupor
Very poor
Immobile
Bedfast
Double E moderate or serious
> 38.3℃ Double use
the Norton Scale
Common Pressure Ulcer Sites
bony prominences
1965 年 Indan等通过研究报告了人在坐和卧位时压迫点的分布,仰卧时,枕骨粗隆、骶尾部、足跟是压迫最重的部位,压力范围 5.3~ 8.0kPa(40 ~
60mmHg) 。
俯卧时膝部和胸部受到的压力接近 6.7kPa(50mmHg)
坐位时 ,集中到坐骨结节的压力高达10kPa(75mmHg) 。
supine position
枕部肩胛部肘部骶尾部足跟部Occipital
scapula elbo
w sacrum
heel
脊椎
spine carina
耳部肩峰肘部髋部踝部 内髁与外 髁
Lateral position
earshoulderelbo
wanterior iliac crest
medial,lateral knee
Medial, lateral malleolus
Prone position
肩峰足趾 膝部 面颊和耳 廓 乳房(女性)生殖器(男性)
cheek (ear)
shoulder Breast
(female)
breast(female) breast(female)
Genitals(male)
genitals(male)
knee
iliac crest, knee
toes
iliac crest
Sitting position
ischium tuber
shoulder
elbow
sole
sacrum
Preventative interventions
Preventative interventions Avoid pressure on local tissues for
prolonged period Reduce shear and friction Protect skin of patients (Hygiene and
skin care) Stimulating blood circulation of skin Provide adequate nutrition Health education
Avoid pressure on local tissues for prolonged period
Turn the patients periodically (every 2 hours or 30 minutes necessarily)
Protect bony prominence and support interspace
Use the devices right, such as plaster, bandage, splint, retractor
Avoid pressure on local tissues in prolonged period
Turn the patients periodically Protect bony prominence and
support interspace Use the devices right
翻身
支被架气垫床褥
Devices used to prevent or treat pressure ulcers
Devices to support pressure areasFlotation pads are pliable pads with a consistency like
body fat, which disperse pressure over a larger area. Pillows and bridging techniques lift the pressure site off the mattress and separate two points of pressure.
Devices to aid in turning a clientA Guttman bed rotates the client from prone to supine
positions and from side to side.Kinetic therapy continuously rotates the client 270
degrees every 3 minutes.
Devices to minimize or equalize pressureAlternating air mattresses made of polyvinyl air cells
are attached to a pump that inflates and deflates them every 3-7 seconds, alternating pressure points.
Water mattresses disperse and evenly distribute the client’s body weight.
High and low air loss bed allow deformation of bed surface to the body contours, thereby reducing tissue pressure below capillary closure. These beds also eliminate shear and friction and reduce moisture.
Reduce shear and friction For bedridden clients,
elevated the head of the bed to no more than 30 degrees.
clients must be positioned, transferred, and turned correctly. lifting rather than dragging
bedpan
Protect skin of patients keep the client’s skin and bedsheet
clean and dry Clean,not soap ; daub ointments, Urine, stool, wound drainage;Vaseline or
zinc oxide Incontinence; diaper
Stimulating blood circulation of skin range-of-motion,ROM Warm water bath in bed: see disc Check and massage skin
Local tissue massage back rub: see disc
Provide adequate nutrition receive sufficient protein, vitamins (A,
C, B1, B 5), and zinc
Health education Educate clients and care givers
regarding pressure ulcer prevention
Treating and nursing pressure ulcer
Stages of Pressure Ulcer Stage I :nonblanchable erythema of intact skin, the
heralding lesion of skin ulceration Stage :Ⅱ Partial thickness skin loss involves damage
or necrosis of epidermis, dermis, or both Stage :Ⅲ Full thickness skin loss involves damage or
necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia
Stage :Ⅳ Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structure such as tendon or joint capsule
瘀血红润期( hyperemia, nonblanchable erythema )
heralding lesion. temporary
circulation lesion Manifestation:
Redness(lightly skin) Red blue,purple hues
(darker skin) Redness, swollenness,
heat, and pain
炎性浸润期(ischemic,inflamation )
epidermis, dermis, or both
Gore,ischemic,
readness and swollenness
enlarged ; color: purple,
not change with pressed ;
superficial abrasion, blister
or shallow crater
浅度溃疡期 (superficial ulceration) subcutaneous
tissue(superficial tissue)
Blister is torn, infection, ichor,necrosis and ulcer
坏死溃疡期 (Necrotic ulceration) Deep dermis,
muscle, bone, tendon or joint capsule
Necrosis turn blue, ichor, septicopyaemia
Treating pressure ulcer Supportive or systemic measures :
providing adequate nutrition Protein status Hemoglobin
Controlling infection : Body substance isolation and good hand
washing technique Local care of the wound
Local care of the wound Stage I
Principle: eliminating risk factors or contributing factors to pressure ulcers
increasing turning frequency, avoiding local tissue pressed long term, improving circulation, keeping bed linen clean, smooth, dry without oddment, reducing friction and shearing force, avoiding excretion and moisture stimulating to skin, increasing nutrition and enhancing immunity and so on.
Moist dressing Toast light Ban massage
Stage Ⅱ Principle:protecting skin and preventing
infection preventive measure followed intensify care of blister
Small untorn blister: big blister: see disc
draw out liquid in blister with sterile injector , unnecessarily scissoring pellicle, and then sterilize the surface and cover it with sterile dressings.
ultraviolet or infrared treatment.
Stage Ⅲ Principle: keeping cleanliness of the ulcer
area Eliminate pressure,keep clean physical therapy: Goosenecked light Moisture-retentive dressings
transparent films, hydrocolloid dressing, and hydrogels
新鲜的鸡蛋内膜、纤维蛋白膜、骨胶原膜等贴于创面
Stage Ⅳ Principle: keeping cleanliness of the ulcer
area, debriding necrotic tissue, keeping drainage smoothly, promoting acestoma growing
Stage Ⅳ Preventive measures Clean and rinse ulcer area: see disc
with sterilized normal saline or 1:5000 Furacilin solution, then covered with sterilized Vaseline gauze or dressings. Metronidazole dressing or be daubed with Sulfapyridine Argentums or Furacilin.
cleansed with 3% Hydrogen Peroxide solution for deep ulcer. keeping drainage smoothly oxygen therapy Surgery: debride necrotic tissue, skin grafting and
skin flap Chinese traditional medicine
Key term Pressure ulcer, pressure sore, decubitus
ulcer, and bedsore Contributing Factors to Pressure Ulcers
Formation Pressure Friction Shearing force Moisture incontinence
Malnutrition obesity Cachexia Dehydration Edema hypoxemic ischemic Orthopedic Devices
plaster, bandage, splint, retractor hypoalbuminemia Mobility Activity Apathetic Bedfast Occipital bone, scapula, spine carina, elbow,
iliac crest, sacrum, heel
ear, shoulder, elbow, anterior iliac crest, trochanter, medial knee, lateral knee, medial malleolus, lateral malleolus
cheek (chin), ear, shoulder, breast(female), genitals(male), iliac crest, knee, toes
ischium tuber, shoulder, elbow, sacrum, sole bony prominence
nonblanchable erythema Partial thickness skin loss Full thickness skin loss Full thickness skin loss with extensive
destruction, tissue necrosis or damage to muscle,
septicopyemia, blister transparent films, hydrocolloid dressing, and
hydrogels debride Sulfapyridine Argentums eschar and slough skin grafting
Objectives Concept of pressure ulcer Contributing Factors to Pressure Ulcers
Formation Patients With High Risk of Pressure
Ulcers Predicting Pressure Ulcers Risk Common Pressure Ulcer Sites
Preventative interventions Stages of Pressure Ulcer and its
manifestation Treating pressure ulcer
谢谢 !
Top Related