Category: Individualised Nursing Care 1 (Part 1)

Pressure ulcers, also known as decubitus ulcer, decubiti, bedsores, pressure sores, pressure injuries, and pressure necrosis, are basically ulcers caused by pressure. Similarly, pressure ulcers can also develop following shearing and friction.

Intrinsic & Extrinsic Causative Factors Leading To Pressure Ulcers

Intrinsic Factors:

• Age
• Malnutrition
• Chronic Illness
• Ischaemia
• Tissue Tolerance – how much the skin and its supporting structures are able to redistribute pressure

Extrinsic Factors:

• Pressure over bone-prominent areas
• Shearing forces eg. patient slides down the bed
• Friction – rubbing of epithelial layer of the skin against another surface

Capillary Pressure

Blood pressure at the arterial end of the capillaries is around 32mmHg, dropping to 10mmHg at the venous end.

Average mean capillary pressure is around 17mmHg. External pressures exceeding this amount is set to cause capillary obstruction.

Tissues dependent on these capillaries become deprived of blood supply, and eventually, these ischaemic tissues die.

• Hyperemia – pressure applied for up to 30 minutes (resolves after an hour)
• Ischaemia – unrelieved pressure for up to 6 hours (may require up to 36 hours to resolve)
• Necrosis – develops after 6 hours of unrelieved pressure with microvasculature collapse and thrombosis
• Ulceration – presents within 2 weeks after necrosis

Pressure Sores Etiology

Avoidable Pressure Ulcers

Pressure ulcers development can be avoided if the healthcare provider follows these 4 steps:

1. EVALUATE the patient’s clinical condition and perform a pressure ulcer risk assessment
2. DEFINE & IMPLEMENT interventions based on the patient’s individual needs and goals
3. MONITOR & EVALUATE how the patient is responding to the interventions
4. REVISE interventions as / if necessary

Pressure Ulcers Risk Assessment

• Bed-bound and chair-bound individuals should be considered as being at risk for pressure ulcers
• Assess higher-risk individuals at admission. Keep assessing at regular intervals as well as with any change in condition.
• Assess patients in acute care on admission and at least every 24 hours, increasing assessment times in case of any change in condition
• Assess patients receiving long term care on admission, followed by weekly assessments for four weeks, spacing to quarterly. Increase frequency of assessment with any change in patient’s condition
• Assess patients receiving community care at home on admission and at every visit
• Consider all risk factors, including decreased mental status, exposure to moisture, incontinence, device-related pressure, friction and shearing, immobility and inactivity, as well as lack of proper nutrition
• Based upon the noted individualised risk assessment, guide patient on related preventative measures and modify or refer to any needed multi-disciplinary team services when necessary
• Document risk assessment and work on the implementation of the individualised prevention and care plan

The Braden Risk Assessment Scale

Waterlow Pressure Ulcer Prevention Assessment

Pressure Injury Staging

Pressure injury staging requires the following considerations:

• history
• visual observation and palpation
• full body (head to toe) skin assessment – consider patient’s position

Following the above, the following is required:

1. clean the pressure ulcer
2. note the deepest anatomic type of soft tissue that has been damaged

Mucosal Membrane Pressure Injuries

Mucosal membrane pressure injury is injury on mucous membranes on which medical devices had to be used. Pressure applied to mucous membranes can cause ischaemia, which then turns into ulceration. Such injuries cannot be staged.

Mucosal membrane pressure injury examples include pressure ulcers which develop on the nasal mucosa from pressure exerted by nasal prongs, and pressure ulcers which develop on the inner lip due to pressure exerted by an endotracheal tube.

Device-Related Pressure Injuries

Device-related pressure injuries are injuries incurred following the use of medical devices applied for diagnostic or therapeutic purposes (excluding devices that come into contact with the mucosal membranes, as mentioned above). Staging of such injuries should be done using the normal staging system.

Pressure Ulcer Classification & Wound Management Considerations

STAGE 1:

• no visible wound
• use a dressing just to cover for protection if necessary

STAGE 2:

• primary non-adherent dressing / antimicrobial dressing for susceptible patients
• secondary absorptive dressing based on exhudate amount

STAGE 3:

• where depth of wound is minimal follow directions for stage 2 (above)

STAGE 4:

• where depth is very deep with dead spaces, manage exhudate and infection, and consider antimicrobials in susceptible patients

UNSTAGEABLE:

• debride if indicated
• if debridement is not indicated, minimise risk of infection by using non-adherent antimicrobial dressing which is ideal for dry wounds

Diagnosis of Pressure Ulcers

Pressure ulcers are sometimes confused with wounds caused by moisture, such as the development of wounds on an incontinent person left with a soiled diaper for a long time. Proper diagnosis is of utmost importance since prevention and treatment varies between pressure ulcers and moisture associated skin damage (MASD).

Tunneling and Undermining

Effective Wound Care Process

Negative Pressure Wound Therapy

Preventing Pressure Ulcers

The Rule of 30⁰

SSkin Care Bundle

Patient Skin Assessment

1. At least once daily (or as suggested further above), perform a head-to-toe skin assessment. Note in particular common sites of pressure ulcer formation, such as the sacrum, ischium, trochanters, heels, elbows, and the back of the head
2. Provide individualised care when it comes to bathing frequency and cleansing agents. Mild cleansing agents are preferred. Do not use hot water and do not towel-rub eccessively so as to avoid damaging the skin. Follow bathing with the use of an appropriate lotion or moisturising agent
3. In patients with incontinence, cleanse skin following soiling and apply a topical barrier to protect the area. Aldanex is an ideal barrier product that helps prevent, protect and promote healing. A pouching system or collection device for faeces can also be considered so as to provide further protection to the skin
4. Use moisturising agents for dry skin and reduce environmental risk factors such as low humidity and cold air. Do not massage bony prominences

Positioning

1. Encourage mobility for patients able to move
2. Reposition bed-bound patients at least every 2 hours; make use of lifting devices during transferring and repositioning of patients
3. Reposition chair/wheelchair-bound patients every 1 hour; consider positional alignment, distribution of weight, balance and stability, and pressure redistribution
4. Use pillows or foam wedges to protect bony prominences from direct contact with each other
5. Follow a written repositioning schedule – if none is available, be proactive!
6. Use pressure-redistributing mattresses and chair cushion surfaces for high-risk patients; DO NOT use donut-type devices and sheepskin for pressure redistribution!
7. Pressure-redistributing devices should also be used in the operating room for high-risk individuals

Nutrition & Hydration

1. Identify patient’s nutrition needs in relation to protein and caloric intake required for individualised care
2. In patients with caloric or nutrition deficit, consider nutritional supplementation
3. Discuss multivitamin and mineral needs for the patient with the physician if needed, and administer as per physician’s orders

Further Considerations

• Is there enough pressure ulcer relief equipment available for high-risk patients?
• Are nursing assessments carried out as per recommendation to avoid the development of pressure ulcers?
• Are nurses providing patient centered care so as to avoid development of pressure ulcers and unnecessary complications in wound care?
• Is enough education on the prevention of pressure ulcers to health care providers, patients and their families, and caregivers, being provided?

Kennedy Terminal Injury

A kennedy terminal injury is a pressure injury which at times tends to develop in individuals who are dying.

These types of pressure injuries start out larger and more superficial than other pressure ulcers, yet develop rapidly in size, depth and colour. In other words, a patient may have no sign of an ulcer in the morning, yet by the afternoon, a dark flat blister would have appeared. Usually, a patient exhibiting a kennedy terminal injury tends to have a life expectancy of between 8 and 24 hours.

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