Transcript Stage Ⅳ

Chapter 5 Assisting Clients With Hygiene
Section 6 Prevention and
Care of Pressure Ulcers
contents
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Contributing Factors to Pressure
Ulcers Formation
Prediction and Prevention of Pressure
Ulcers
Treating and nursing pressure ulcer
Economic consequences of pressure
ulcers
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Frequency:
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3-14%,2-25%(nursing home)
85.7% paraplegia
58% pressure ulcer ＞ 65y
Economic consequences:
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Days in hospital increase
Cost of heath care increase: $4,000-40,000
Pressure ulcer
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.
Contributing Factors to Pressure
Ulcers Formation
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Factor of pressure
Pressure
 Friction
 Shearing force
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Moisture irritation to the Skin
 Nutritional Status
 Age
 Fever (infection)
 Orthopedic Devices
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Factor of pressure
Shearin
剪切力
g force
Friction
摩擦力
Pressur
垂直
e 压力
Moisture irritation to the Skin
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urinary and fecal incontinence
wound drainage
sweat
Nutritional Status
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Malnutrition
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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)
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increase the body’s metabolic rate
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increasing the needs of the cells for oxygen
Make hypoxemic tissue more susceptible to
ischemic injury
diaphoresis
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increased skin moisture irritation
Orthopedic Devices
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plaster, bandage, splint, retractor
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reduce mobility of the client or of an
extremity
friction
pressure
Prediction and Prevention of Pressure
Ulcers
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Assessment
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Patients With High Risk of Pressure Ulcers
Predicting Pressure Ulcers Risk
Common Pressure Ulcer Sites
Preventative interventions
Patients With High Risk of
Pressure Ulcers!
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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
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predictive instruments
the Braden Scale
 the Norton Scale
 the Gosnell and Knoll instruments
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the Braden Scale
Items/points 4
3
2
1
Activity
Walks
frequently
Walks
occasionally
Chairfast
Bedfast
Mobility
No
Slightly
limited
Very limited
Completely
immobile
limitations
Friction
shear
and Not at all
No apparent Potential
problem
problem
Problem
Slightly
limited
Completely
Sensory
perception
No
impairment
Moisture
Rarely moist Occasionally Very moist
moist
Nutrition
Excellent
Adequate
Very limited
limited
Probably
inadequate
Constantly
moist
Very poor
the Norton Scale
Items/points 4
3
2
1
Mental
condition
Nutrition
condition
Mobility
Alert
Apathetic
Confused
Stupor
Good
Fair
Poor
Very poor
Full
Slightly
limited
Very limited
Immobile
Activity
Ambulatory Walks
help
Incontinence
Absent
Urine
incontinence
Circulation
Capillary
promptly
Capillary
slowly
Temperature
Medications
36.6-37.2℃
37.2-37.7℃
Not
with Chair-bound
Fecal
incontinence
Edema
slightly
37.7-38.3℃
Administering steroidal
drugs
sedatives
Bedfast
Double
E moderate
or serious
＞38.3℃
Double use
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)。
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俯卧时膝部和胸部受到的压力接近6.7kPa(50mmHg)
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坐位时,集中到坐骨结节的压力高达10kPa(75mmHg)。
supine position
spine
carina
足
跟
部
heel
骶
尾 脊 肘
部 椎 部
sacrum
肩 枕
胛 部
部 Occipital
elbow scapula
Lateral position
踝
部
内髁与
外 髁
髋
部
肘 肩 耳
部 峰 部
Medial,
ear
lateral
medial, anterior
elbow shoulder
malleolus lateral iliac crest
knee
Prone position
breast(female)
genitals(male)
iliac
crest, knee
足
趾
toes
膝
部
肩 面颊和
生殖器 乳房
峰 耳 廓
（男性）
（女性）
knee Genitals
(male)
iliac
crest
Breast
(female)
shoulder cheek
(ear)
Sitting position
shoulder
elbow
sacrum
ischium
tuber
sole
Preventative interventions
Preventative interventions
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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
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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
翻身
Avoid pressure on local
tissues in prolonged period
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Turn the patients periodically
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Protect bony prominence and
support interspace
Use the devices right
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支被架
气垫床褥
Devices used to prevent or treat
pressure ulcers
Devices to support pressure areas
Flotation 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 client
A 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 pressure
Alternating 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
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For bedridden clients,
elevated the head of the
bed to no more than 30
degrees.
clients must be
positioned, transferred,
and turned correctly.
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lifting rather than dragging
bedpan
Protect skin of patients
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keep the client’s skin and bedsheet
clean and dry
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Clean,not soap ; daub ointments,
Urine, stool, wound drainage;Vaseline or
zinc oxide
Incontinence; diaper
Stimulating blood circulation of
skin
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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
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receive sufficient protein, vitamins (A,
C, B1, B 5), and zinc
Health education
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Educate clients and care givers
regarding pressure ulcer prevention
Treating and nursing
pressure ulcer
Stages of Pressure Ulcer
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Stage I :nonblanchable erythema of intact skin, the
heralding lesion of skin ulceration
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Stage Ⅱ: Partial thickness skin loss involves damage
or necrosis of epidermis, dermis, or both
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Stage Ⅲ: Full thickness skin loss involves damage or
necrosis of subcutaneous tissue that may extend down
to, but not through, underlying fascia
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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 ）
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heralding lesion.
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temporary
circulation lesion
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Manifestation:
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Redness(lightly skin)
Red blue,purple hues
(darker skin)
Redness, swollenness,
heat, and pain
炎性浸润期
(ischemic,inflamation )
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epidermis, dermis, or both
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Gore,ischemic,
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readness and swollenness
enlarged；color: purple, not
change
with
pressed；
superficial abrasion, blister
or shallow crater
浅度溃疡期(superficial
ulceration)
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subcutaneous
tissue(superfi
cial tissue)
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Blister is torn,
infection,
ichor,necrosis
and ulcer
坏死溃疡期(Necrotic ulceration)
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Deep
muscle,
tendon
capsule
dermis,
bone,
or joint
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Necrosis turn blue,
ichor,
septicopyaemia
Treating pressure ulcer
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Supportive or systemic measures ：
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providing adequate nutrition
 Protein status
 Hemoglobin
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Controlling infection ：
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Body substance isolation and good hand
washing technique
Local care of the wound
Local care of the wound
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Stage I
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Principle: eliminating risk factors or contributing
factors to pressure ulcers
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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
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Principle:protecting skin and preventing
infection
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preventive measure followed
intensify care of blister
Small untorn blister:
 big blister: see disc
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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
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Principle: keeping cleanliness of the ulcer
area
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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
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Stage Ⅳ
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Principle: keeping cleanliness of the ulcer
area, debriding necrotic tissue, keeping
drainage smoothly, promoting acestoma
growing
Stage Ⅳ
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Preventive measures
Clean and rinse ulcer area: see disc
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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
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Pressure ulcer, pressure sore, decubitus
ulcer, and bedsore
Contributing Factors to Pressure Ulcers
Formation
Pressure
Friction
Shearing force
Moisture
incontinence
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Malnutrition
obesity
Cachexia
Dehydration
Edema
hypoxemic
ischemic
Orthopedic Devices
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plaster, bandage, splint, retractor
hypoalbuminemia
Mobility
Activity
Apathetic
Bedfast
Occipital bone, scapula, spine carina, elbow,
iliac crest, sacrum, heel
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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
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nonblanchable erythema
Partial thickness skin loss
Full thickness skin loss
Full thickness skin loss with extensive
destruction, tissue necrosis or damage
to muscle,
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septicopyemia,
blister
transparent films, hydrocolloid dressing, and
hydrogels
debride
Sulfapyridine Argentums
eschar and slough
skin grafting
Objectives
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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
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Preventative interventions
Stages of Pressure Ulcer and its
manifestation
Treating pressure ulcer