NCM 118 RLE

PRESSURE ULCER
CARE
GROUP MEMBERS
Raymundo, Jhon Rhey
Paquera, Kim
Marquez, Alfritzie
Serato, Lloyd
Sansaet, Shannarey

CLINICAL INSTRUCTOR:
Mrs. Mavie C. Gomez RN, MAN
 1. Define the following terms:
a. Pressure
b. Pressure ulcer
After 3 hours of c. Pressure ulcer care
classroom discussion d. Induration
demonstration, the
e. Erythema
Level IV nursing
students will be able to: f. Maceration
g. Debridement
h. Exudates

2
 2. Explain the significance of ulcer care in relation to
the nursing practice
3. Distinguish different factors frequently act in
conjunction with pressure to produce pressure ulcer
4. Recite some etiology in producing pressure ulcer
E S 5. Differentiate the classification of bed sores
T IV 6. Enumerate signs and symptoms of bed sores

J EC development

O B 7. Cite out the different techniques in preventing the

development of bed sores

3
 8. Identify different treatments in bed sores
9. Illustrate different types of dressing used for
pressure ulcer

E S 10. Enumerate the guidelines in pressure ulcer

T IV care

EC
11. State the different principles of infection

B J control in patient with pressure ulcer

O 12. Discuss the different nursing responsibilities
before, during, and after pressure ulcer care

4
DEFINITION OF TERMS

– a compressing downward force

on a body area.

PRESSURE

(Source: Kozier and Erb’s Fundamentals of Nursing pg.

1456) 5
 – are localized areas of necrotic soft tissue that occur when
pressure applied to the skin over time is greater than normal
capillary closure pressure, which is about 32 mmHg.
Patients who are prone to pressure ulcers include those
confined to bed for long periods, those with motor or
sensory dysfunction, and those who experience muscular
atrophy and reduction of padding between the overlying skin
PRESSURE and the underlying bone.

ULCERS

(Source: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing page 424) 6

 - Pressure ulcer care is an important part of nursing
practice. Most pressure ulcers are avoidable and nurses
should ensure that all appropriate measures are taken to
reduce harm and risk factors and prevent pressure ulcer
development whenever possible.
PRESSURE
ULCER
CARE

(Source: www.magonlinelibrary.com) 7
 - an abnormally hard lesion or reaction, as in
a positive tuberculin skin test.

INDURATION

(Source: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing page

1227) 8
 - redness of the skin caused by
congestion of the capillaries

ERYTHEMA

(Source: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing page 3694) 9

 – the wasting away or softening of a
solid as if by the action of soaking;
often used to described degenerative
changes and eventual disintegration.

MACERATION

(Source: Kozier and Erb’s Fundamentals of Nursing pg. 1452) 10

 - removal of necrotic or dead tissue
by mechanical, surgical, chemical,
or autolytic means.

DEBRIDEMENT

(Source: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing page 3723) 11

 – purulent drainage

EXUDATES

(Source: Source: Source: Kozier and Erb’s Fundamentals of Nursing

pg. 1446) 12
 - Pressure ulcers are a major healthcare issue
and are associated with pain, infection,
prolonged hospital stays, and in extreme
cases can be a causative factor in a patient’s
SIGNIFICANCE OF death.
ULCER CARE IN
RELATION TO THE - It is important to use a structured approach that
NURSING PRACTICE involves skin assessment and identification of
risks.

(Source: The Royal Marsden Manual of Clinical Nursing Procedures 9th edition page 946) 13
 - The risk assessment should be carried out by a Registered Nurse or
healthcare professional who has undergone appropriate training to
recognize the risk factors that contribute to the development of
pressure ulcers and how to initiate and maintain correct and suitable
prevention measures.

- The use of assessment tools should be undertaken in conjunction with

clinical judgement.

(Source: The Royal Marsden Manual of Clinical Nursing Procedures 9th edition page 946) 14
 The three major extrinsic factors that are
identified as being significant contributory
factors in the development of pressure ulcers
DIFFERENT are:
FACTORS
1. pressure
FREQUENTLY
2. shearing
ACT IN
3. friction
CONJUNCTION
WITH These factors should be removed or
PRESSURE diminished to reduce injury. An individual’s
potential for developing pressure ulcers may
be influenced by the following intrinsic
factors.
15
 INTRINSIC FACTORS

• Reduced mobility or immobility

• Acute illness
• Level of consciousness
• Extremes of age
• Vascular disease
• Severe, chronic or terminal illness

(Source: The Royal Marsden Manual of Clinical Nursing Procedures 9th edition page 946) 16
 INTRINSIC FACTORS

• Previous history of pressure damage

• Malnutrition and dehydration
• Neurologically compromised
• Obesity
• Poor posture

(Source: The Royal Marsden Manual of Clinical Nursing Procedures 9th edition page 17
  Pressure ulcers are due to localized ischemia, a
deficiency in the blood supply to the tissue.
 The tissue is compressed between two surfaces.
 When blood cannot reach the tissue, the cells are
deprived of oxygen and nutrients, the waste products
ETIOLOGY IN of metabolism accumulate in the cells, and the tissue
consequently dies.
PRODUCING  Prolonged, unrelieved pressure also damages the
PRESSURE small blood vessels.
 When pressure is relieved, the skin takes on a bright
ULCER red flush, called reactive hyperemia. The flush is due
to vasodilation, a process in which extra blood floods
to the area to compensate for the preceding period of
impeded blood flow.

(Source: Kozier and Erb’s Fundamentals of Nursing page 18

858)
19
CLASSIFICATION OF BED SORES
(ACCORDING TO STAGES)

20
 -Intact skin
-Non-blanchable redness of a localized area, usually
over a bony prominence
-Darkly pigmented skin may not have visible
STAGE 1 blanching.
-Color may differ from surrounding area.
CLASSIFICATION -Area may be painful, firm, soft, and warmer or
OF BED SORES cooler as compared to adjacent tissue.
(ACCORDING TO
STAGES)

21
 - Partial thickness loss of dermis, presenting as a shallow
open ulcer with red-pink wound bed without slough
-May present as an intact or open/ruptured serum-filled
blister-may present as a shiny or dry shallow ulcer
STAGE 2 without slough or bruising; bruising indicates suspected
deep tissue injury
-Does not include skin tears, tape burns, perineal
CLASSIFICATION dermatitis, maceration, or excoriation
OF BED SORES
(ACCORDING TO
STAGES)

22
 -Full-thickness tissue loss Subcutaneous fat may be visible; however,
bone, tendon, or muscle is not exposed.
-Slough may be present but does not obscure the depth of tissue loss.
-May include undermining and tunneling
-Depth of a stage III pressure ulcer varies by anatomic location. The bridge
STAGE 3 of the nose, ear, occiput, and malleolus do not have subcutaneous tissue;
stage III ulcers can be shallow in these areas.
-Areas of significant adiposity can develop extremely deep stage III
CLASSIFICATION pressure ulcers.
OF BED SORES
(ACCORDING TO
STAGES)

23
 -Ulcer presents with full-thickness tissue loss with exposed bone,
tendon, or muscle.
-Slough or eschar may be present on some parts of the wound.
-Often includes undermining and tunneling
-Depth of a stage IV pressure ulcer varies by anatomic location. The
bridge of the nose, ear, occiput, and malleolus do not have
STAGE 4 subcutaneous tissue; stage IV ulcers can be shallow in these areas.
-Stage IV ulcers can extend into muscle and/or supporting structures
CLASSIFICATION (e.g., fascia, tendon, or joint capsule); osteomyelitis is possible.
OF BED SORES -Exposed bone/tendon is visible or directly palpable.

(ACCORDING TO
STAGES)

24
 SUSPECTED DEEP TISSUE INJURY

There may be a purple or maroon localized area of discolored

intact skin or blood-filled blister.
-The area may be preceded in appearance by tissue that is
painful, firm, mushy, boggy, and warmer or cooler as
compared to adjacent tissue.
-Evolution may include a thin blister over a dark wound bed.
CLASSIFICATION -The wound may further evolve and become covered by thin
OF BED SORES eschar.
(ACCORDING TO -Evolution may be rapid, exposing additional layers of tissue even
with optimal treatment.
STAGES)

25
 UNSTAGEABLE
Full-thickness tissue loss in which the base of the ulcer is covered
by slough (yellow, tan, gray, green, or brown) and/or eschar (tan,
brown, or black) in the wound bed
-Until enough slough and/or eschar is removed to expose the base of
the wound, the true depth, and therefore stage, cannot be
determined.
-Stable (dry, adherent, intact without erythema or fluctuance)
CLASSIFICATION escharon the heels serves as “the body’s natural (biological) cover”
OF BED SORES and should not be removed.
(ACCORDING TO
STAGES)

(Sources: Brunner & Suddhart’s

Med-Surg Pg.635-637) 26
(Source: The Royal Marsden Manual of Clinical Nursing Procedures 9th edition page 946) 27
 11 ERYTHEMA

TISSUE ISCHEMIA OR
22
ANOXIA

33
SMALL VESSEL
THROMBOSIS

44 SERUM ALBUMIN
LESS THAN 3 g/dl
SIGNS AND 55 SINUS TRACT
SYMPTOMS
66
SPASTIC MUSCLE
AND PARALYSIS

77 MACERATION

88 PURULENT
DRAINAGE
DRYING AND CRUSTING
(Sources: Brunner & Suddhart’s Med-Surg Pg. 629-632) 99 28
OF EXUDATES
 A. Topical Skin Care and Incontinence Management

• Perform frequent skin assessment at a minimum on a

once-a-day basis. However, high risk patients have more
DIFFERENT frequent skin assessments such as every shift.
TECHNIQUES IN • Ensure that the patient’s skin is clean and dry.
• When you clean the skin, avoid soap and hot water.
PREVENTING • Use cleaners with non-ionic surfactants that are gentle to
THE the skin.
• After you clean the skin and make sure that it is completely
DEVELOPMENT dry, apply moisturizer to keep the epidermis well lubricated
OF BED SORES but not oversaturated.
• Make an effort to control, contain, or correct incontinence,
perspiration, or wound drainage.

(Fundamentals of Nursing 8th edition, Potter & Perry, page 1196) 29

 B. Positioning
• Change the immobilized patient’s position according to activity level,
perceptual ability, and daily routines.
• Patients need repositioning on a schedule of at least every 2 hours if
DIFFERENT allowed by their overall condition. When repositioning, use positioning
devices to protect bony prominences.
TECHNIQUES IN • The WOCN (Wound, Ostomy, and Continence Nurses Society)
PREVENTING guidelines (2010) recommend a 30-degree inclined lateral position
which should prevent positioning directly over the bony prominence.
THE • To prevent shear and friction injuries, use a transfer device to lift rather
than drag the patient when changing positions.
DEVELOPMENT • Teach a mobile patient at risk for skin breakdown in a sitting position to
shift weight every 15 minutes. Also have him or her sit on foam, gel, or
OF BED SORES an air cushion to redistribute weight away from the ischial areas.
• After repositioning the patient, reassess the skin.
• Never massage the reddened areas

(Fundamentals of Nursing 8th edition, Potter & Perry, pages 1196-

1197) 30
IDEAL POSITIONING
TO PREVENT/REDUCE
PRESSURE ULCERS IN
LYING

31
 C. Support Surfaces (Therapeutic Beds and Mattresses)

• A support surface is a specialized device for pressure

redistribution designed for management of tissue loads,
microclimate, and/or other therapeutic functions (i.e., mattresses,
DIFFERENT integrated bed system, mattress replacement, overlay or seat
TECHNIQUES cushion, or seat cushion overlay).
• A variety of support surfaces, including specialty v and
IN mattresses, reduce the hazard of immobility to the skin and
PREVENTING musculoskeletal system.
• No single device eliminates the effects of pressure on the skin.
THE • When selecting support surfaces, incorporate the patient’s
DEVELOPMENT needs.
• In selecting a support surface, know the patient’s risks and the
OF BED SORES purpose for the support surface.
• When used correctly, these support services help reduce
pressure ulcers in patients at
risk.
(Fundamentals of Nursing 8th edition, Potter & Perry, pages 1197-1199) 32
DIFFERENT
TREATMENTS
IN BED SORES

33
 STAGE 1

A. TRANSPARENT DRESSING B. HYDROCOLLOID DRESSING

A. WOUND
DRESSINGS

(Saunders Comprehensive Review for the NCLEX-RN Examination 7th 34

edition, Silvestri, pages 552-553)
 STAGE 2
A. COMPOSITE FILM B. HYDROGEL
DRESSING DRESSING

A. WOUND
DRESSINGS

(Saunders Comprehensive Review for the NCLEX-RN Examination 7th 35

edition, Silvestri, pages 552-553)
 STAGE 3
A. HYDROGEL
COVERED WITH B. GAUZE DRESSING
FOAM DRESSING

A. WOUND
DRESSINGS

(Saunders Comprehensive Review for the NCLEX-RN Examination 7th 36

edition, Silvestri, pages 552-553)
 STAGE 4
A. HYDROGEL COVERED B. GAUZE DRESSING
WITH FOAM DRESSING WITH SOLUTION

A. WOUND
DRESSINGS

C. CALCIUM ALGINATE

(Saunders Comprehensive Review for the NCLEX-RN Examination 7th 37

edition, Silvestri, pages 552-553)
 UNSTAGEABLE
B. GAUZE DRESSING
A. ADHERENT FILM WITH SOLUTION

A. WOUND
DRESSINGS

(Saunders Comprehensive Review for the NCLEX-RN Examination 7th 38

edition, Silvestri, pages 552-553)
 - Debridement is the removal of nonviable, necrotic
tissue. Removal of necrotic tissue is necessary to rid
the wound of a source of infection, enable visualization
of the wound bed, and provide a clean base necessary
for healing.

B. DEBRIDEMENT - It may be accomplished by wet-to-damp dressing

changes, mechanical flushing of necrotic and infective
exudate, application of prescribed enzyme
preparations that dissolve necrotic tissue, or surgical
dissection.

(Fundamentals of Nursing 8th edition, Potter & Perry page 1199)

(Brunner & Suddarth’s Textbook of Medical-Surgical Nursing14th edition, Hinkle & Cheever,
39
page645)
  Electrical Stimulation to The
Wound Area
 Vacuum Assisted Wound
Closure
OTHER
 Hyperbaric Oxygen Therapy
TREATMENTS
 Use Of Topical Growth Factors

(Saunders Comprehensive Review for the NCLEX-RN Examination 7th edition, Silvestri, pages 552) 40
DIFFERENT TYPES
OF DRESSING

41
DRESSING
MATERIALS

42
DRESSING
MATERIALS

43
DIFFERENT
DRESSINGS WITH ALIGINATE BIOLOGICAL
DRESSING
PICTURES

COTTON GAUZE 44
DIFFERENT
DRESSINGS

FOAM
45
DIFFERENT
DRESSINGS

HYDROCOLLOID DRESSING 46
DIFFERENT
DRESSINGS

HYDROGEL
47
DIFFERENT
DRESSINGS

ADHESIVE TRANSPARENT FILM

48
DIFFERENT
DRESSINGS

ADHESIVE TRANSPARENT FILM

49
 THERAPEUTIC PRESSURE SORES RELIEF
MATTRESS

T IC
P EU
R A
H E E D
T B

50
 AIRE MATTRESS ANTI BED SORE ALTERNATING
PRESSURES SYSTEM

T IC
P EU
R A
H E E D
T B

51
 Anti Bedsore Bedridden Patients Elderly/Bed Wedge Pillow Elevation Support Cushion
Pad Set for Leg Back Knee Waist Wheelchair

T IC
P EU
R A
H E E D
T B

52
 ALTERNATING AIR PRESSURE MATTRESS

T IC
P EU
R A
H E E D
T B

53
 ANTI-BEDSORE PILLOWS

T IC
P EU
R A
H E E D
T B

54
 ULTRA PRESSURE SORE PREVENTION FOR
WHEELCHAIR

T IC
P EU
R A
H E E D
T B

55
 1. Identify clients at risk for developing a pressure injury.
2. Institute measures to prevent pressure injury, such as
appropriate positioning, using pressure relief devices,
ensuring adequate nutrition, and developing a plan for skin
cleansing and care.
3. Perform frequent skin assessments and monitor for an
alteration in skin integrity
GUIDELINES IN 4. Keep the client’s skin dry and the sheets wrinkle-free; if the
PRESSURE client is incontinent, check the client frequently and change
ULCER CARE pads or any items placed under the client immediately after
they are soiled.
5. Use creams and lotions to lubricate the skin and a barrier
protection ointment for the incontinent client.
6. Turn and reposition the immobile client every 2 hours or
more frequently if necessary; provide active and passive
range-of-motion exercises at least every 8 hours.

56
 7. If a pressure injury is present, record the location and size
of the wound (length, width, depth in centimeters), monitor
and record the type and amount of exudates (a culture of the
exudate may be prescribed), and assess for undermining and
tunneling. Depending on agency policy, it may be required to
have picture documentation on file of a pressure injury or
GUIDELINES IN other disruption in skin integrity that may include a client
PRESSURE identifier, measuring device, and a label indicating wound
laterality and location. If a wound or other skin problem is
ULCER CARE
noted, it may be necessary to request a referral to a wound
care and/or nutrition specialist.

8. Serosanguineous exudate (blood-tinged amber fluid) may

be noted; purulent exudates indicate colonization of the
wound with bacteria.

57
 9.Use agency protocols for skin assessment and
management of a wound.

10.Treatment may include wound dressings and

debridement; skin grafting may be necessary.

GUIDELINES IN 11.Other treatments may include electrical

PRESSURE stimulation to the wound area (increases blood
vessel growth and stimulates granulation), vacuum-
ULCER CARE assisted wound closure (removes infectious
material from the wound and promotes granulation),
hyperbaric oxygen therapy (administration of
oxygen under high pressure raises tissue oxygen
concentration), and the use of topical growth factors
(biologically active substances that stimulate cell
growth).

58
  Standard Precaution
 hand hygiene
 PPE (mask, gloves, gown, goggles)
PRINCIPLES OF
INFECTION
CONTROL IN
PATIENT WITH
PRESSURE
ULCER

59
 BEFORE:
 Ensure the lighting is good, preferably natural or
fluorescent.
 Regulate the environment before beginning the
assessment.
NURSING  Inspect pressure areas for discoloration.
RESPONSIBILITIES  Inspect pressure areas for abrasion and
excoriation.
 Palpate surface temperature of the skin over the
pressure areas.
 Palpate over bony prominences and dependent
body areas for the presence of edema.

60
 DURING:
 Clean and dress the ulcer using surgical
asepsis. NEVER use alcohol or hydrogen
peroxide because they are cytotoxic to
NURSING tissue beds.
RESPONSIBILITIES
 If pressure ulcer is infected, obtain a sample
of the drainage for culture and sensitivity.

61
 AFTER:
 Document the following:
 Location of the pressure ulcer.
 Length, width, and depth of the pressure ulcer.
NURSING  Stage of the pressure ulcer.
RESPONSIBILITIES
 Clinical signs of infection (redness, warmth,
swelling, pain, odor, and exudate)
 Teach client to move frequently to relieve
pressure.

(Source: Kozier and Erb’s Fundamentals in Nursing 12th ed.

Pg. 834, 838, 846) 62
 https://www.youtube.com/watch?v=C_U
yC8l8-Vw

VIDEO LINKS: https://www.youtube.com/watch?v=K2Z

KGonZqUQ

63
THANKS!
Any questions?

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