CARE OF PRESSURE PONTS / BED SORE

CARE OF PRESSURE POINTS/BEDSORE

A bedsore or pressure sore decubitus ulcer is an ulcer occurring on the skin of any bed-ridden patient, particularly over bony prominences or where two skin surfaces press against each other

Bedsore is a term applied to the local gangrene or ulcer caused by certain conditions associated with the confinement of bed. Due to constant pressure, circulation becomes slow and finally death of tissues occurs

Definitions

Pressure injury: a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, shear and/or friction, or a combination of these factors

pH: a measure on a scale from 0 to 14 of the acidity or alkalinity of a solution, with 7 being neutral, greater than 7 is more alkaline and less than 7 is more acidic

Blanching erythema: reddened skin that blanches white under light pressure

Risk assessment scale: a formal scale or score used to help determine the degree of pressure injury risk. At the Royal Children’s Hospital the Glamorgan Risk Assessment Scale is currently used

Shear: it is a mechanical force created from parallel loads that cause the body to slide against resistance between the skin and a contact surface. The outer layers of the skin (the epidermis and dermis) remain stationary while deep fascia moves with the skeleton, creating distortion in the blood vessels between the dermis and deep fascia. This leads to thrombosis and capillary occlusion

Friction: it is a mechanical force that occurs when two surfaces move across one another, creating resistance between the skin and contact surface that leads shear

Extrinsic factors: originating outside of the body

Intrinsic factors originating within the body

Moisture: alters resilience of the epidermis to external forces by causing maceration, particularly when the skin is exposed for prolonged periods. Moisture can occur due to split fluids, incontinence, wound exudates and perspiration

Aims: the primary objectives are to promote prevention of pressure injuries and provide optimal care to patients at risk of, or with existing pressure injuries. The guideline specifically seeks to assist health professionals to:

  • Improve knowledge of the underlying physiology of pressure injury formation
  • Recognize factors which contribute to pressure injuries
  • Identify high risk patients
  • Implement and document intervention and prevention strategies
  • Prevent or delay complications associated with pressure injuries
  • Optimize management of pressure injuries
  • Provide adequate parent and care education

Purpose

  • To improve circulation
  • To facilitate healing
  • To prevent infection
  • To prevent further damage
  • To treat bedsores

Clients Susceptible to Bedsores

  • Actually ill clients, whose general condition is rapidly deteriorating
  • Elderly bedridden clients who make very little movements in bed
  • Obese clients
  • Very thin and emaciated clients, having very little subcutaneous tissue to pad the bony prominences
  • Sedated clients who have suffered spinal cord injuries
  • Paralyzed clients, who have suffered spinal cord injuries
  • Neurologic clients with lack of sensations that they cannot feel any irritation of the skin
  • Edematous clients especially those with edema of the sacrum and buttocks
  • Malnourished clients with protein and vitamin deficiencies
  • Agitated clients in restraints
  • Surgical clients with limited movements
  • Clients on complete bed rest or with limited movements

Cause of Pressure Sores

  • Direct or immediate cause: the pressure is caused by the weight of the body continuously remaining in one position, splints, casts and bandages
  • Friction: friction of the skin with rough bedding causes injury to the skin. The friction is caused by wrinkles in the bed cloths, cramps of food in the bed, chipped or rough bed pans and hand surfaces of plaster casts and splints
  • Moisture: the skin contact with moisture for a prolong period can lead maceration of the skin
  • Pressure of pathogenic organisms due to unhygienic condition pathogenic organism multiplies and infection settles on the skin

Predisposing Factors

  • Patient with long term illness, fracture patients
  • Patients with spinal injury
  • Paralysis and limited movements
  • Emaciated and malnourished patients
  • Elderly with circulatory problems
  • Obese patients
  • Edematous patients
  • Patients with incontinence
  • Diabetic patients with ulcers (diabetic foot)

Common Sites Liable to Get Bedsore

  • In supine position: occiput, scaptula, sacral region, hips and elbow
  • In side lying position: ears, acromion process of shoulder, ribs, greater trochanter of hips medial and lateral condyles of knee and malleolus of ankle joint
  • In prone position: ears cheeks acromion process, breast in female genitalia, knees and toes

Clinical Manifestations of Pressure Sore

  • Redness, heat, tenderness, and discomfort in the area
  • The area becomes cold to touch and insensitive
  • Local edema
  • Later, the area becomes blue, purple of mottled
  • Due to continued pressure that circulation is cut off, the gangrene develops and affected area is sloughed

Preventive Measures of Bedsores

  • Confirm the high-risk patients and daily examination for the signs and symptoms
  • Relieve pressure by using special mattress, beds and comfort devices
  • Change position and giving back care four times a day for all bedridden patients
  • Loosening tight bandages and restraints
  • Avoid friction by providing smooth, firm and wrinkle free bed, keep  the bottom clothes free from crumbs and foreign bodies
  • Prevent moisture by changing linen when, it is wet or soiled. Giving back care to patients immediately following micturition and defecation
  • Avoid mechanical or physical injury to the skin from improper fitting of prosthesis or from burns caused by excessively hot or cold applications
  • Use a bed cradle to lift the weight of bed linen off the patient to enable him or her to move in bed freely
  • Supply well-balanced diet and adequate fluids to maintain general health of the patient

Stages/Degree of Pressure Sores Based on

The early symptoms of pressure sore are redness, tenderness, discomfort, and smarting. The area becomes cold to touch and insensitive. There is local edema. Later the area becomes blue, purple or muted. Due to continued pressure, the circulation is cut off, the gangrene develops and the affected area is sloughed off

Clinical Manifestations

First degree: the skin is red, tender, inflamed and painful

Second degree:  the skin is blue or mottled insensitive, circulation cut off, gangrene develops and epidermis breaks

Third degree: suppuration and sloughing occurs which may burrow right down to the bones

Curative Measures Based on Degrees of Pressure Sores

First degree: detect the early signs and symptoms of bedsore and report them to the sister in charge and the doctor

Carry out all the preventive measure with special care to prevent extension of bedsore and further occurrence of pressure sores

While giving back care/massage, do not over the reddened or inflamed area itself but start just outside the affected area and move outwards in a circle using circular motion

Consult the doctor for further treatment

Second degree: if the pressure sore is blue or mottled insensitive, circulation cut off gangrene develops or epidermis breaks

The treatment included:

  • Inform and report to the ward sister and physician
  • Prevent and ulcerated area from infection
  • Use normal saline for cleaning the area
  • Sloughing is more; use hydrogen peroxide solution also for cleaning, cut off the slough
  • Apply heat for healing of the wound. Use 100 watt electric bulb for 10 minutes
  • Apply zinc oxide ointment on the surface of the wound

Third degree: if the bedsore is suppuration and sloughing occurs which may burrow right down to the bones

  • Inform and report to the ward sister and physician
  • To treat infection, apply soframycin ointment locally and give systemic antibiotics after culture and sensitivity
  • Provide nutritious diet (high in protein and vitamins) sunlight and fresh air
  • If slough is present, clean the wound with hydrogen peroxide twice daily if the slough is loose, it may be cut off
  • If there is delay in wound healing, skin grafting can be done

After Care

  • Place the patient in comfortable position
  • Use proper and adequate comfort devices
  • Change the patient’s position at frequent intervals
  • Remove the articles from the bedside and replace it in a proper place
  • Hand washing

Recording and reporting-date time, type  of pressure sore and treatment in the nurses record

CARE OF PRESSURE PONTS / BED SORE - Definition, Purpose, Cause, Prevention, Clinical Manifestations, After care
CARE OF PRESSURE PONTS / BED SORE – Definition, Purpose, Cause, Prevention, Clinical Manifestations, After care

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