Bed sores pressure ulcer Question grid Write two

Bed sores (pressure ulcer)

Question grid • • Write two question which starting by: Why When Where Who What How

Definition: it is any area of damage to the skin or underlying tissues caused by direct pressure or shearing forces.

Risk factors in Pressure Ulcer Development 1. External pressure Usually occur over bony prominences. Where body weight is distributed over a small area without much subcutaneous tissue to cushion damage to the skin.

Posterior knee

Friction and shearing forces • Friction occurs when two surfaces rub against each other. • Shearing forces results when one layer of tissue slides over another layer. • The small blood vessels and capillaries in the area are stretched and possibly tear.

Immobility Sits or lies most of the time is at risk for pressure sores because immobility causes prolonged pressure on body area. Nutrition and Hydration Protein - caloric malnutrition Predisposed a persons to pressure ulcer formation because poorly nourished cells are easily damaged

• Vitamin C deficiency to become fragile. capillaries • Dehydration interfere with circulation and subsequent cell nourishment (weight loss). Moisture : - • prolonged moisture on the skin reduces the skin’s resistance to trauma.

Mental states: delirium or dementia Age : - older adult are at greater risk for pressure sore formation because the aging skin is more susceptible to injury.

Pressure ulcer staging: A-Stage one erythema may be appear red or violet. B-Stage two breakdown of the derms

C-Stage three Full thickness skin breakdown. D-Stage four Bone, muscle, and supporting tissue involved.

Signs and symptoms Foul odor from ulcer Redness/tenderness around ulcer Warm/swollen skin Fever, weakness, and confusion if infection spread to blood or other areas of body.

Nursing Assessment: 1 -Assess the risk factors. 2 -Assess skin of older people frequently. 3 -Assess stage of ulcer Prevention of ulcer : 1 -Inspect skin several times daily. 2 -Wash skin with mild soap, rinse, and dry with soft towel. 3 -Lubricate skin with a bland lotion

To keep the skin soft. 4 - Avoid poorly ventilated mattress that is covered with plastic or impermeable material. 5. Enhance bowel and bladder programs to prevent incontinence. 6 -Encourage ambulation and exercise. 7 -Promote nutrition diet with optimal protein vitamins, and iron.

Relive the pressure: 1 -Avoid elevation of the head of bed greater than 30 degree. 2 -reposition every 2 hours. 3 -Use special devices to protect specific areas, such as flotation rings, elbow pads. 4 -Use an alternating-pressure mattress for patients at high risk to prevent or treat pressure ulcer. 5 -Provid for activity and ambulation as much as possible.

5 PILLOW RULE 1. Pillow 1 under legs to elevate heels (or Prevelon Heel Protectors) 2. Pillow 2 between ankles if on side 3. Pillow 3 between knees if on side 4. Pillow behind the back (unless you are using the Turn and position unit) 5. Pillow 5 under the head

Clean the ulcer: 1 -Use normal saline for cleaning and Disinfecting wound. 2 -Apply topical antibiotic to locally infected pressure ulcer as prescribe.

Sever bed ulcer

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