Pressure ulcer

Doesn't it make you really mad at whoever is responsible for this? I do. Every time when I see a picture of pressure ulcer, I get super mad. I decide to not be a nurse who has a patient with pressure ulcer every time. Really. I won't be.

So here are nursing interventions for prevention.

• Maintain clean, dry skin and wrinkel-free linens;
• Appropriately use pressure-reducing surfaces and pressure-relieving devices
• Inspect skin frequently and document risk using a tool such as the Braden scale
• Clean and dry skin immediately following urinary or stool incontinence
• Apply moisture barrier creams to the skin of clients who are incontinent
• Use tepid water (not hot), minimal scrubbing, and pat skin dry.

• Reposition the client in bed at least every 2 hr and every 1 hrs when sitting in a chair. Document position changes;
• Place pillows strategically between bony surfaces
• Maintain the head of the bed at or blow a 30 degree angle (or flat), unless contraindicated, to relieve pressure on sacrum, buttocks, and heels
• Prevent the client from sliding down in bed, as this increases shearing forces that pull tissue layers apart and cause damage
• Lift rather than pull a client up in bed or in a chair, because pulling creates friction that can damage the client's outer layer of skin (epidermis)
• Raise the client's hells off of the bed to prevent pressure on the heels
• Ambulate the client as soon as possible and as often as possible
• Implement active/passive exercises for immobile clients
• Do not massage bony prominences

• Provide adequate hydration (2,000 to 3,000 mL/day) and meet protein and calorie needs;
• Note if serum albumin levels are low (less than 3.5)
• Provide nutritional support as indicated, such as vitamin and mineral supplements, nutritional supplements, enteral nutrition, and parenteral nutrition

(Assessment Technologies Institute)

Here are risk factors for development of pressure ulcers

• Skin changes related to aging
• Immobility.
• Incontinence or excessive moisture.
• Skin friction and shearing.
• Vascular disorders.
• Obesity.
• Inadequate nutrition and or hydration.
• Anemia.
• Fever.
• Impaired circulation.
• Edema.
• Sensory deficits.
• Impaired cognitive functioning, neurological disorders.
• Chronic diseases (e.g., diabetes mellitus, chronic renal failure, congestive heart disease, chronic lung disease).
• Sedation that impairs spontaneous repositioning. (Assessment Technologies Institute)

Bibliography

Assessment Technologies Institute. Fundamentals for Nursing . Ed. Jeanne Wissmann. 6.1. ATI, 2008.