Presentation on theme: "PRESURE ULCERS PRESENTED BY"— Presentation transcript:
1 PRESURE ULCERS PRESENTED BY MRS NGOZI OKORIE-IGWEAT THE MANDATORY CONTINUING PROFESSIONALDEVELOPNMENT PROGRAMME (MCPDP)ORGANIZED BY:(N&MCN) AND IMO STATE M. C. P.D. P IMPLEMENTATION COMMITTEE.VENUE: NEWTON HOTEL OWERRIDATE: 7TH -11Th JULY, 2014
2 INTRODUCTIONPressure ulcers also called decubitus ulcers or bed sores are localized ulcerated areas of the skin caused by continuous external pressure on that part of the body. The unrelieved pressure impairs the flow of blood and lymph which results in tissue ischemia, necrosis ,and eventual ulceration.
3 OBJECTIVES At the end of this session, participants should be able to: Define pressure ulcers and explain the pathophysiologyIdentify pressure areas and those at risk of pressure of pressure ulcersDescribe the staging of pressure ulcers
4 OBJECTIVES CONTINUEDUtilize the nursing process to collect data, establish outcome, provide individualized care and evaluate responses for clients with pressure ulcers.
5 REVIEW OF ANATOMY AND PHYSIOLOGY OF THE SKIN The primary organ involved in pressure ulcer is the skin.The skin is composed of three layers namely:The outer epidermisThe middle dermisThe inner subcutaneous
6 ANATOMY AND PHYSIOLOGY OF THE SKIN CONTINUED The skin also consist of accessory organs namely:Hair shaft, hair follicle, sebaceous gland, sweat glands, erector pilli muscles, nerve endings and blood vessels.The skin performs various functions such as:Protection against biological invasions, physical damage and ultraviolet radiation
7 ANATOMY AND PHYSIOLOGY OF THE SKIN CONTINUED Provision of sensation by the nerve endings for touch pain and heat.Thermoregulation through sweating and regulation of blood flow through the skin.Synthesis of vitamin DExcretion of waste which occurs with the production of sweat.
9 PRESSURE AREASThese are areas of the body where the tissues may be compressed between the bed and the underlying bone. They include: the occiput, ears, scapula,spinous process, shoulder, elbow, iliac crest, sacrum/coccyx ,ischeal tuberosity, trochanter, knee, heel, toe.
10 THOSE AT RISK FOR PRESSURE ULCERS Older patients with impaired mobility: Age related changes such as thicker epidermis and thinner dermis with decreased vascularity, sebaceous gland activity and decreased strength and elasticity thus they respond slowly to inflammation and wound healing.Patients with quadriplegia and spinal cord injury.
11 THOSE AT RISK FOR PRESSURE ULCERS Patients who have nutritional deficits, incontinence and are unconscious.Patients with fractured femur and hip bone.Heavy patients who are pulled up in bed instead of being lifted.
12 PRESSURE ULCER STAGING Pressure ulcers are graded or staged to classify the degree of damage and describe the clinical manifestationsSTAGE 1:The skin is intact but there is redness of a localized area, usually over a bony prominence
16 PRESSURE ULCER STAGING CONTINUED STAGE III:There is full thickness tissue loss, subcutaneous fat may be visible but the bones, tendon or muscle are not exposed. slough may be present but does not obscure the depth of the wound.
22 PATHOPHYSIOLOGYOF PRESSURE ULCER Lying or sitting in a position for an extended length of time without moving puts pressure on the tissue between a bony prominence and the external surface of the body, distorts capillaries and interferes with normal blood flow. If the pressure is relieved ,blood flow to the area increases, a brief period of reactive hyperemia occurs and no permanent damage occurs. However if the pressure continues, platelets form small blood clots
23 PATHOPHYSIOLOGY OF PRESSURE ULCERS CONTINUED In the capillaries and impede blood flow, resulting in ischemia and hypoxia of the tissues. Eventually the cells and tissues of the immediate area and of the surrounding area die and become necrotic as the tissues die, the ulcer becomes an open wound that may be deep enough to expose the bones.
24 PATHOPHYSIOLOGY OF PRESSURE ULCERS CONTINUED The necrotic tissues elicit an inflammatory response which precipitates fever, pain and increased white blood cell count in the patient. With secondary bacterial invasion, the necrotic tissues are dissolved resulting in foul smelling drainage.
25 DIAGNOSTIC ASSESSMENT CLINICAL TOOL: Braden scale is one of the clinical tools used to asses a patient’s risk for developing pressure ulcer by examining six criteria namely:1)sensory perception: This is the ability to respond to discomfort or pain that is related to pressure on the parts of the body.
26 DIAGNOSTIC ASSESSMENT CONTINUED 2) Moisture: Excessive and continuous skin moisture can pose a risk to compromise the integrity of the skin e.g immobility, sweat and incontinence.3) Activity :Clients level of activity if little or none at all, can lead to atrophy of muscles and breakdown of tissues
27 DIAGNOSTIC ASSESSMENT CONTINUED 4) Mobility: This deals with the capacity of a patient to adjust their body position independently.5) Nutrition: Imbalanced nutrition can alter skin integrity.6) Friction: This refers to the amount of assistance to move and the degree of sliding in bed and chairs. Sliding motions can cause shearing.
28 DIAGNOSTIC ASSESSMENT CONTINUED Each of the Braden scale criteria scores 1-4, the lowest being 6 and the highest 23.The lower the score the higher the risk.LABOURATORY TESTS: These are conducted to determine the presence of a secondary infection and to differentiate the cause of the ulcers. If the ulcer is deep or appears infected ,drainage or biopsied tissue is cultured to determine the causative organism.
29 NURSING MANAGEMENT OF PRESSURE ULCERS The nursing management of pressure ulcers involves prevention of those at risk and the promotion of healing process for those with pressure ulcers. However surgical management may be necessary if the ulcer is deep and the subcutaneous tissues are involved, also if a scab has formed over the ulcer preventing healing by granulation, large wounds may require skin grafting for complete closure.
30 SPECIFIC NURSING DIAGNOSES Risk for impaired skin integrity.Impaired skin integrity.DIAGNOSIS: Risk for impaired skin integrityPLAN: To maintain and improve intact skin integrity.IMPLEMENTATION: Identify patients at risk using the Braden scale risk assessment tool.
31 IMPLEMENTATION CONTINUED Conduct a systematic skin inspection at least once a day paying particular attention to the bony prominences. Report changes such as bruising and redness promptly.Minimize friction or shearing forces by lifting patients rather than dragging during positioning, transfer or turning.
32 IMPLEMENTATION CONTINUED Minimize exposure to moisture from incontinence by changing underpants frequently and cleaning skin with mild cleansing agent.Bath patients with mild antiseptic soap and treat dry skin with moisturizers. Do not massage over bony prominences as this may lead to deep tissue trauma.
33 IMPLEMENTATION CONTINUED Encourage adequate dietary intake of protein and calories as this promotes skin integrity.Reposition and turn patients at least every two hours as this relieves pressure over bony prominences.
34 IMPLEMENTATION CONTINUED Use position device such as pillows to protect bony prominences and use of special mattress (water bed) to distribute patients more evenly.EVALUATIONPatient maintained intact skin integrity throughout period of hospitalization.
35 SPECIFIC NURSING DIAGNOSIS DIAGNOSIS: Impaired skin integrity.PLAN: To promote healing of the pressure ulcers.IMPLEMENTATION: Monitor the appearance of the pressure ulcer and drainage if any.
36 IMPLEMENTATON CONTINUED Change dressing as prescribed following strict sterile technique.Apply topical and systemic antibiotics as prescribed to eradicate any infection present and to promote healing.EVALUATION: There is progressive healing of the pressure ulcers.
37 CONCLUSIONThis presentation has looked at the pathophysiology of pressure ulcers, pressure areas , those at risk for pressure ulcers, pressure ulcer staging, diagnostic assessment and nursing management of pressure ulcers. It is important to note that pressure ulcers are preventable if proper nursing management is effectively and efficiently implemented.
39 REFERENCESBarbara, F. (2010).Nurses dictionary. London: Bailliere Tindall publishers.Bedsores. Retrieved from www. mayoclinic. com/health/bedsores.Burke, M. Mohn-Brown,L. & Eby, L.(2011). Medical Surgical Nursing care New Jersey: Pearson education incorporated.
40 REFERENCES CONTINUEDPressure ulcer prevention. Retrieved from options.com.Pressure ulcerss causes diagnosis and treatment-clinical key.Retrieved from key.com.Pressure ulcer category/staging illustration.retrieved from
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