2. Pressure ulcer — also called pressure sores or
Bed sores or decubitus ulcer — are injuries to
skin and underlying tissue resulting from
prolonged pressure on the skin.
3.
4. • Bedsores most often develop on skin that
covers bony areas of the body, such as the
heels, ankles, hips and tailbone.
• People most at risk of bedsores are those with
a medical condition that limits their ability to
change positions, requires them to use a
wheelchair or confines them to a bed for a
long time.
5. CAUSES
• Bedsores are caused by pressure against the
skin that limits blood flow to the skin and
nearby tissues.
• Other factors related to limited mobility can
make the skin vulnerable to damage and
contribute to the development of pressure
sores.
6. Three primary contributing factors are:
• Sustained pressure.
When the skin and the underlying
tissues are trapped between bone and a surface
such as a wheelchair or a bed, the pressure may
be greater than the pressure of the blood
flowing in the tiny vessels (capillaries) that
deliver oxygen and other nutrients to tissues.
Without these essential nutrients, skin cells and
tissues are damaged and may eventually die.
7. • This kind of pressure tends to happen in areas
that aren't well-padded with muscle or fat and
that lie over a bone, such as spine, tailbone,
shoulder blades, hips, heels and elbows.
8. • Friction.
Friction is the resistance to motion. It
may occur when the skin is dragged across a
surface, such as when change position or a care
provider moves the patient. The friction may be
even greater if the skin is moist. Friction may
make fragile skin more vulnerable to injury.
9. • Shear.
Shear occurs when two surfaces
move in the opposite direction.
For example, when a hospital bed is elevated
at the head, you can slide down in bed. As the
tailbone moves down, the skin over the bone may
stay in place — essentially pulling in the opposite
direction.
This motion may injure tissue and blood
vessels, making the site more vulnerable to
damage from sustained pressure.
10. RISK FACTORS
People are at risk of developing pressure sores if
they have difficulty moving and are unable to easily
change position while seated or in bed. Immobility
may be due to:
– Generally poor health or weakness
– Paralysis
– Injury or illness that requires bed rest or wheelchair
use
– Recovery after surgery
– Sedation
– Coma
11. Other factors that increase the risk of
pressure sores include:
• Age.
The skin of older adults is generally more fragile,
thinner, less elastic and drier than the skin of younger
adults. Also, older adults usually produce new skin cells
more slowly. These factors make skin vulnerable to
damage.
• Lack of sensory perception.
Spinal cord injuries, neurological disorders and
other conditions can result in a loss of sensation. An
inability to feel pain or discomfort can result in not
being aware of bedsores or the need to change
position.
12. • Weight loss.
Weight loss is common during prolonged
illnesses, and muscle atrophy and wasting are
common in people with paralysis. The loss of fat
and muscle results in less cushioning between
bones and a bed or a wheelchair.
• Poor nutrition and hydration.
People need enough fluids, calories, protein,
vitamins and minerals in their daily diet to
maintain healthy skin and prevent the breakdown
of tissues.
13. • Excess moisture or dryness.
Skin that is moist from sweat or lack of
bladder control is more likely to be injured and
increases the friction between the skin and
clothing or bedding. Very dry skin increases
friction as well.
• Bowel incontinence.
Bacteria from fecal matter can cause
serious local infections and lead to life-
threatening infections affecting the whole body.
14. • Medical conditions affecting blood flow.
Health problems that can affect blood flow,
such as diabetes and vascular disease, increase
the risk of tissue damage.
• Smoking.
Smoking reduces blood flow and limits the
amount of oxygen in the blood. Smokers tend to
develop more-severe wounds, and their wounds
heal more slowly.
15. • Limited alertness.
People whose mental awareness is
lessened by disease, trauma or medications may
be unable to take the actions needed to prevent
or care for pressure sores.
16. PATHOPHYSIOLOGY
Continuous external pressure over the soft
tissue between the boney prominence and hard
surface may cause compression of the capillaries
and cause impairment of blood flow.
When the pressure continuous the platelets will
get aggregated in the capillaries and forms
microthrombi.
17. • The thrombi which was formed in the
capillaries will increase the resistance ,
ischemia and hypoxia, which will eventually
leads to tissue death and necrosis.
18. CLINICAL FEATURES
• Pain
• Localized edema
• Blister formation
• Formation of lesion
• Tissue necrosis
• Erythema
• Warmness around the inflamed area
19. STAGES
STAGE I
• The skin is not broken.
• The skin appears red on people with lighter
skin color, and the skin doesn't briefly lighten
(blanch) when touched.
• On people with darker skin, the skin may show
discoloration, and it doesn't blanch when
touched.
• The site may be tender, painful, firm, soft,
warm or cool compared with the surrounding
skin.
20. Stage II
• The outer layer of skin (epidermis) and part of
the underlying layer of skin (dermis) is
damaged or lost.
• The wound may be shallow and pinkish or red.
• The wound may look like a fluid-filled blister
or a ruptured blister.
21. Stage III
• The loss of skin usually exposes some fat.
• The ulcer looks crater-like.
• The bottom of the wound may have some
yellowish dead tissue.
• The damage may extend beyond the primary
wound below layers of healthy skin.
22. Stage IV
• A stage IV ulcer shows large-scale loss of tissue:
• The wound may expose muscle, bone or tendons.
• The bottom of the wound likely contains dead
tissue that's yellowish or dark and crusty.
• The damage often extends beyond the primary
wound below layers of healthy skin.
23. DIAGNOSIS
• Proper history collection
• Physical examination
• Diagnosis is made from clinical features
• Blood studies include protein, albumin and
hemoglobin and it helps to find out any signs
of malnutrition
• Bone studies helps to identify the signs of
involvement of bones.
24. TREATMENT
Stage I and II bedsores usually heal within
several weeks to months with conservative care
of the wound and ongoing, appropriate general
care. Stage III and IV bedsores are more difficult
to treat.
25. • The first step in treating a bedsore is reducing
the pressure that caused it. Strategies include
the following:
– Repositioning.
If patient have a pressure sore, you need
to be repositioned regularly and placed in correct
positions.
26. • Using support surfaces.
Use a mattress, bed and special
cushions that help you lie in an appropriate
position, relieve pressure on any sores and
protect vulnerable skin.
27. Cleaning and dressing wounds
• Cleaning.
It's essential to keep wounds clean to
prevent infection. If the affected skin is not
broken (a stage I wound), gently wash it with
water and mild soap and pat dry. Clean open
sores with a saltwater (saline) solution each
time the dressing is changed.
28. • Applying dressings.
A dressing promotes healing by
keeping a wound moist, creating a barrier
against infection and keeping the surrounding
skin dry.
Dressing choices include films, gauzes,
gels, foams and treated coverings.
29. Removing damaged tissue
• Surgical debridement
it involves cutting away dead tissue.
• Mechanical debridement
in this loosens and removes wound debris.
This may be done with a pressurized irrigation
device, low-frequency mist ultrasound or
specialized dressings.
30. • Autolytic debridement
it enhances the body's natural process of
using enzymes to break down dead tissue.
This method may be used on smaller, uninfected
wounds and involves special dressings to keep
the wound moist and clean.
• Enzymatic debridement
it involves applying chemical enzymes and
appropriate dressings to break down dead
tissue.
31. Other interventions
• Pain management.
Pressure ulcers can be painful.
Nonsteroidal anti-inflammatory drugs — such as
ibuprofen (Motrin IB, Advil, others) and
naproxen (Aleve, others) — may reduce pain.
• Antibiotics.
Infected pressure sores that aren't
responding to other interventions may be
treated with topical or oral antibiotics.
32. • A healthy diet.
To promote wound healing, doctor or
dietitian may recommend an increase in calories
and fluids, a high-protein diet, and an increase
in foods rich in vitamins and minerals.
33. NURSING MANAGEMENT
• Assess the specific risk factors for pressure
ulcer.
• Determine the client’s age and general
condition of the skin.
• Assess the client’s nutritional status, including
weight, weight loss, and serum albumin levels,
if indicated.
34. • Assess the skin on admission and daily for an
increasing number of risk factors.
• Assess for a history of radiation therapy.
• Assess the client’s awareness of the sensation
of pressure.
• Assess for fecal and urinary incontinence.
• Assess client’s ability to move
35. • Assess the surface that the clients spend a
majority of time on.
• Assess the client’s level of pain, especially
related to dressing change and procedures.
