Unit # 06 Skin Management Insta Husain.z.kmu

Pressure Ulcer/Bed Sores & Skin
Management
By : Ibne Amin
Institute of Nursing Sciences,
Khyber Medical University , Peshawar
Pressure Ulcer/Bed Sores & Skin
Management
At the end of the session , learners will be able to:
1. Define decubetic ulcer (bed sore)
2. List the causes of decubetic ulcer
3. Identity risk Factars of bedsores
4. Apply nursing interventions to prevent
decubetic ulcer.
Insta ; husain.z.kmu
Anotomy of Skin
Skin consists of 3 main layers

• Epidermis :
-the superfaicial portion of the skin
-composed of epithelial tissue
• Dermis :
-the deeper layer of the skin
-Primirily composed of connective tissue
• Hypodermis :
- also called the subcutaneous layer
-Consists of areolar and adipose tissue
Anotomy of Epidermis
The epidermis is the outer layer that forms the protective covering. A
protective barrier of stratified squamous epithelium consisting of 5
layers
1 .Stratum corneum: 20-30 rows of flat dead cells continually shed ,surrounded by lipid
hence water repellent. Barrier to light, heat,water,chemicals & bacteria
2. Stratum lucidum: 3-4 layers clear flat dead cells ,contain precursor of keratin.
Present only in the finger tips,palms of the hand, & soles of the feet
3. Stratum granulosum: Cells degenerating with production of keratin
4. Stratum spinosum: 8-10 rows of cells that produce protein but can not
duplicate ,provide strength and flexibility. Langerhan cells
5. Stratum basale: Deepest layer made of columnar cells continually dividing, gradually
migrating to surface. Merkle cells, Melanocytes, stem cells ,keratinocytes
Anotomy of Epidermis
Four principle Cells of Epidermis:

• Melanocytes: Produce melanin pigment causing brown
colouration of skin and protects skin from UV light damage
• Langerhan Cells: Immune cells which help in defence.
Situated in stratum spinosum, they help process and present
foreign antigens to the immune system
• Merkel Cells: Within the basal layer, close to hair follicles;
involved in touch sensation
• Keratinocytes : Produce the protein Keratin, which help protect
the skin and underlying tissue from heat, chemicals, and microbes
Anotomy of Dermis
Connective tissue layer composed of collagen &

elastic fibres,fibroblasts, macrophages and fat
cells.Contain hair follicles,glands,nerves and
blood vessels.
It is consists of 2 layers:
• Papiliary dermis
• Reticular dermis
Anotomy of Dermis
1: Papiliary dermis: The upper 20% layer of

dermis.Finger like projection are called dermal papillea
that anchors epidermis to dermis. It has extensions
protruding into the epidermis called Rete pegs which
also contain small capillary loops that feed epidermis.
• Meissner’s corpuscles (sensation of touch, shape and
texture) ,
• Pacinian corpuscles (deep pressure and vibrational
sensation) , and
• free nerve ending for sensation of heat , cold ,pain .
Anotomy of Dermis
Reticular dermis:
• The lower layer of dermis.
• It is dense irregular connective tissue ,made up of
collagen, elastin and ground substance as well as hair
follicles, sweat and sebaceous glands
• provide strength, extensibility and elasticity to the
skin.
Anotomy of Dermis
Fibroblasts are the predominant cell type in the dermis and

produce collagen and elastin which provide strength and
flexibility to the skin.In addition, there are blood vessels,
sebaceous glands, sweat glands, hair follicles, sensory
receptors and fat cells.
• Myofibroblasts - contractile, important in healing of wounds
• Macrophages - derived from vascular leucocytes; phagocytic and
stimulate fibroblasts
• Mast cells - contain histamine
• Lymphocytes - mediate immune function
• Sensory receptors
Functions of the Skin
• Physical barrier (Protection )

• Vitamin D production
• Immunity
• Sensation
• Identity
• Temperature control (thermoregulation)
• Excretion and Absorbtion
Pressure Ulcer/ Bed sores
A Pressure Ulcer or Bed Sore or Decubitus Ulcer is a localized injury
to the skin and underlying tissue,usually over a body prominence,as
a result of prolonged unrelieved pressure.
OR
A pressure ulcer is a wound with localized area of tissue necrosis.
It is also known as pressure sore, bed sore, Decubitus Ulcer or
distortion sore.
Depending on the depth of the ulcer a pressure ulcer may be an
acute wound or chronic wound.
The underlying cause is pressure.
Most pressure ulcers develop when soft tissue is compressed between a bony prominences and external surface
for a prolonged period of time.
Pressure Ulcer/ Bed sores
Two mechanisms contribute to the pressure ulcer

development.
1. External pressure that compressed blood vessels
2. Friction and shearing forces that tear and injure
blood vessels and abrade the top layer of skin.
Friction: it is a force acting parallel to skin surface.
e.g. sheet rubbing.
Shearing force: It is the combination of friction and
pressure, commonly occur due to Fowler’s position.
Pathophysiology of Pressure Ulcers
Etiology of Pressure Ulcer
Pressure ulcers are due to localized ischemia,a

deficiency in the blood suply to the tissue.The tissue
is compressed between two surfaces, usually the
surface in the bed and the boney skeleton,with
greater than 32 mm of pressure. As a result the
tissue is deprived of oxygen & other nutrients and
consequently the tissue dies.
Reactive Hyperemia Vasodialation
Common Sites of Pressure Ulcers
A) Supine Position
• Heels (calcaneus)
• Sacrum
• Elbows (olecranon process)
• Scapulae
• Back of Head (Occipetal bone)
B) In lateral position
• Malleolus (medial & leteral)
• Knee (medial & lateral condyles)
• Greater trochantor
• Ilium
• Shoulder (acromial process)
• Ear
• Parietal and temporal bone
C) In Prone position
• Toes (phalanges)
• Knee (patellas)
• Genitalia (men)
• Breast (women)
• Shoulder (acromial process)
• Cheek and ear (Zygomatic bone)
D) Fowler’s Position
• Heels (calcaneus)
• Pelvic (ischial tuberosity)
• Sacrum
• Vertebrae (spinal processes)
Risk Factors
Risk Factors
Intrinsic Extrinsic
Risk Factors
1) Intrinsic Factors perception

• Malnutrition
• Dehydration • Altered mental status
• Age>70 years • Impaired circulation,
• Decreased mobility • Illness
• Increased temperature (malignancy, diabetes,
Excessive perspiration stroke, pneumonia, heart
• failure, sepsis, hypotension,
• Urinary/fecal renal failure, anemia,
incontinence, immunocompromised
patients
• Decreased sensory
Risk Factors
2) Extrinsic Factors
• Pressure
• Shear
• Friction
• Moisture
Other factor contributing to the formation of bed sores
are poor lifting or transferring techniques,incorrect
positioning,hard support surfaces etc
Stages of Pressure Ulcer
Based ,on the observable depth of tissue

damage,there are four stages of ulcers
Stage 1
Stage 2
Stage 3
Stage 4
In 2007, two new stages were added:
Suspected deep tissue injury and Unstageable.
Stage 1 Pressure ulcer

Skin is intact and shows a non blanchable, localized
redness or erythema over a bony prominence.
Redness remains after pressure is released. Signs and
symptoms may include pain, firm, soft, warm or cool
compared to adjacent tissue. – EPIDERMIS
Involves only the epidermal layer of skin

A partial thickness wound. Superficial break in
the epidermis or partial thickness loss of
dermis. Presents as a shiny or dry shallow
ulcer without slough or bruising. In this stage
the ulcer may be refered as blister or abrasion

Skin break with deep tissue involvement down to
subcutaneous layer. Full thickness skin tissue loss.
Subcutaneous fat may be visible but 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.
Epidermis ,dermis and subcutanous tissue involved.

Skin break with deep tissue involvement down
to the bone, tendon, or muscle. Full thickness
tissue loss with exposed bone, tendon or
muscle. Slough or eschar may be present on
some parts of the wound bed. Often include
undermining and tunneling. Stage 3 and 4 are
considered Full Thickness wounds.
Unstageable: Full thickness tissue loss in which

the base of the ulcer is covered by slough
(yellow, gray, green or brown) and/or eschar
(brown or black) in the wound bed.
The slough or eschar must be removed before
the true stage can be determined.
Suspected Deep Tissue Injury (SDTI):
It is a purple or maroon localized area of

discoloured intact skin or blood filled blister
because of damage to underlying soft tissue.
Level of tissue necrosis is suspected to be deep.
Risk Assessment
Several scales exist to assess patients at risk for

pressure ulcer development.eg
• The Norton Scale
• Braden Scale
• Waterlow scale
Beside this,we also use (PUSH )3.0 tool for monitoring
Ulcer healing
PUSH=Pressure Ulcer Scale for Healing
Pressure ulcer management
Pressure Ulcer management include:
 Prevention
Treatment
Prevention
Bed sores are easier to prevent than to treat.Although

wound can develop inspite of the most scrupolous
care,it is possible to prevent them in many cases.
1). Position Changes
2). Skin Inspection
3). Nutrition
4). Lifestyle changes
5). Use pressure relieving devices
Prevention
1). Position Changes:

Changing position frequently and consistently is crucial
to preventing bed sores. Expert advise shifting
position about every 15 minutes that you are in a
wheel chair and atleast once every two hours,even
during the night, if you spend most of your time in
bed.
Prevention
Rule of 300
Reposition bedridden patients according to the
“ Rule of 30”
• HOB elevated no more than 30 degree
• Place body in 30, laterally incline position
• Hips and shoulder 30 from supine
• Support with pillow or wedges
Prevention
2). Skin Inspection: Daily skin inspection for

pressure ulcer & skin care , is an intrgral part of
prevention
3). Nutrition: A healthy diet is important in
preventing skin breakdown and in wound
healing. Adequate hydration to maintain the
skin integrity. Because an inadequate intake of
calories,protein, vitamins and iron is believed to
be a risk factor for pressure Ulcer development.
Prevention
4). Lifestyle changes:

Quitting smoking
Exercise- Daily exercise improve circulation
5).Pressure-relieving Devices:
Such as air mattress, water mattress.
So prevention focuses on local pressure reduction, Skin care,
improve general condition
Treatment of PU
1) Changing Position often.

2) Using support surfaces
3) Cleaning
4) Controlling incontinence
5) Removal of damaged tissue(debridement).
6) Dressing
7) Oral antibiotics
8) Healthy Diet.
9) Surgical repair
Role of Nurse in prevention &
Management of Bed Sores
The Nurse must continuously assess the client who are
at risk for pressure ulcer development
Assess the client for:
• The predisposing factors for bed sore development.
• Skin condition at least twice a day.
• Inspect each pressure site.
• Palpate the skin for increased warmth.
• Inspect for dry skin, moist skin, breaks in skin
Role of Nurse in prevention &
Management of Bed Sores
• Evaluate level of mobility
• Evaluate circulatery status (edema,periphral pulse)
• Assess neurovascular status
• Determine presence of Incontinence
• Evaluate nutritional and hydration status
• Note present health problems
Nursing Interventions
Patient with decreased sensory perception

• Assess pressure points for signs of bed sore development
• Provide pressur-redistribution surface.
Patient with Incontinence
• Assess need for incontinence management.
• Following each incontinent episode, clean area and dry
thoroughly
• Protect skin with moisture-barrier ointment.
Intervention to avoid Friction and shear

• Reposition patient using draw sheet and lifting off surfaces
• Avoid dragging the patient in bed.
• Use proper positioning technique.
• Use comfort devices appropriately.
Patient with decreased Activity or mobility
• Establish individualized turning schedule
• Change position at least once in two hours & more frequently
for the highest risk individuals.
Clients with poor Nutrition

• Provide adequate nutrition and fluid intake.
• Assist with intake as necessary.
• Consult dietition for nutritional evaluation.
• Evaluate the ulcer progress every 4-6 days.
• Assist the physician or surgeon in debridement.
• Educate the patient and family regarding the risk factors and
prevention of bed sores.
References
kozier & Erb’s Fundamental of Nursing ,8th

edition( Audrey Berman ,Shirlee J. Synder).

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Unit # 06 Skin Management Insta Husain.z.kmu

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Pressure Ulcer/Bed Sores & Skin

Skin consists of 3 main layers

Four principle Cells of Epidermis:

Connective tissue layer composed of collagen &

1: Papiliary dermis: The upper 20% layer of

Fibroblasts are the predominant cell type in the dermis and

• Physical barrier (Protection )

Two mechanisms contribute to the pressure ulcer

Pressure ulcers are due to localized ischemia,a

1) Intrinsic Factors perception

Based ,on the observable depth of tissue

Stage 1 Pressure ulcer

Stage 2 Pressure ulcer

Stage 3 Pressure ulcer

Stage 4 Pressure ulcer

Unstageable: Full thickness tissue loss in which

Suspected Deep Tissue Injury (SDTI):

It is a purple or maroon localized area of

Several scales exist to assess patients at risk for

Pressure Ulcer management include:

Bed sores are easier to prevent than to treat.Although

1). Position Changes:

2). Skin Inspection: Daily skin inspection for

4). Lifestyle changes:

1) Changing Position often.

Patient with decreased sensory perception

Intervention to avoid Friction and shear

Clients with poor Nutrition

kozier & Erb’s Fundamental of Nursing ,8th

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