Nursing Care of Immobilized Client Nursing Care of Immobilized Client Objectives: 1. Define bedsore. 2. List factors enhance the incidence of bedsores. 3. Identify the pressure areas in different positions. 4. State the classification of bed sores according to damaged skin layers. 5. Apply the nursing process in caring for client having bed sore. Nursing Care of Immobilized Client Outlines: 1. Definition of bedsore. 2. Factors enhance the incidence of bedsores. 3. Pressure areas in different positions. 4. Classification of bed sores according to damaged skin layers. 5. Application of nursing process in caring for client having bed sore. Nursing Care of Bed Sores Bedsores, more properly known as pressure ulcers or decubitus ulcers. Definition: are lesions caused by many factors such as: Unrelieved pressure. Friction (is the resistance to movement). Humidity. Nursing Care of Bed Sores Shearing forces (forces that push the body down). Temperature. Age. Continence. Medication. Pressure Areas Nursing Care of Bed Sores Classification • Stage I is the most superficial, indicated by non blanchable redness that does not subside after pressure is relieved. This stage is visually similar to reactive hyperemia seen in skin after prolonged application of pressure. Nursing Care of Bed Sores • Stage II is damage to the epidermis extending into, but no deeper than the dermis. In this stage, the ulcer may be referred to as a blister or abrasion. Nursing Care of Bed Sores • Stage III involves the full thickness of the skin and may extend into the subcutaneous tissue layer. This layer has a relatively poor blood supply and can be difficult to heal. At this stage, there may be undermining damage that makes the wound much larger than it may seem on the surface. Nursing Care of Bed Sores • Stage IV is the deepest, extending into the muscle, tendon or even bone. Nursing Care of Bed Sores • Unstageable pressure ulcers are covered with dead cells and wound exudates, so the depth cannot be determined. Nursing Care of Bed Sores Nursing assessment: Assess the client for: The predisposing factors for bed sore development. Skin condition at least twice a day. Inspect each pressure sites. Palpate the skin for increased warmth. Inspect for dry skin, moist skin, breaks in skin. Nursing Care of Bed Sores Note drainage and odor. Evaluate level of mobility. Note safety and assistive devices (eg. Restraints, splints). Evaluate circulatory status (eg. Peripheral pulses, edema). Assess neurovascular status. Determine presence of incontinence. Nursing Care of Bed Sores Evaluate nutritional and hydration status. Review the patient’s record for laboratory studies. Note present health problems. Review current medications. Nursing Care of Bed Sores Nursing diagnosis: 1. Risk for impaired skin integrity. 2. Impaired skin integrity R/T immobility, decreased sensory perception, decreased tissue perfusion, decreased nutritional status, friction, and shear forces, excessive moisture. Nursing Care of Bed Sores Goals of nursing care: Reducing friction and shear. Improving sensory perception. Promote pressure ulcer healing. Nursing Care of Bed Sores Nursing intervention: Relieving pressure (change position, turning and repositioning 1-2 hours intervals). Nursing Care of Bed Sores Nursing Care of Bed Sores Use pressure-relieving devices as high density foam, air or liquid mattress overlays. Specialized beds have been designed to prevent pressure on skin. Nursing Care of Bed Sores Mobility & Immobility Nursing Care of Bed Sores Improving mobility: the patient encouraged to stay active and is ambulated whenever possible. Improving tissue perfusion (exercise and repositioning). Active and passive exercises. Range of Motion Exercises Flexion of the head and neck Extension of the head and neck Lateral flexion of the head and neck Rotation of neck. Extension of the shoulder Flexion of the shoulder Abduction of the shoulder Adduction of the shoulder Internal and external rotation Flexion and extension of the elbow of the shoulder Flexion of the finger Extension of the finger Adduction of the finger Abduction of the finger Flexion and extension of the hip Abduction of the hip Adduction of the hip Internal rotation of the hip External rotation of the hip Flexion of the knee Extension of the knee Dorsiflexion of the ankle Plantar flexion of the ankle Inversion of the ankle Eversion of the ankle Flexion of the toes Extension of the toes Adduction of the toes Abduction of the toes Nursing Care of Bed Sores Begin nutritional intervention with dietary supplements and nutrients including, but not limited to, glutamine, vitamin A, vitamin B complex, vitamin E, vitamin C, magnesium, manganese and zinc. It is very important that intake of these vitamins and minerals be overseen by a physician, as many of them can be detrimental in incorrect dosages. Nursing Care of Bed Sores Treatment: Debride the dead tissues. Cultures of infected pressure ulcers are obtained to guide the selection of antibiotic therapy. multiple agents and protocols are used to treat pressure sores, but consistency is an important key to success. Nursing Care of Bed Sores Evaluate the ulcer progress every 4-6 days. Take photographs at weekly interval to observe healing process. Surgical intervention is necessary if the ulcer is extensive. Nursing Care of Bed Sores Treatment • The most important thing to keep in mind about the treatment of bedsores is that the most optimal outcomes find their roots in a multidisciplinary approach; by using a team of specialists, there is a better chance that all bases will be covered in treatment. • There are seven major contributors to healing. Nursing Care of Bed Sores Debridement The removal of necrotic tissue is an absolute must in the treatment of pressure sores. Because dead tissue is an ideal area for bacterial growth, it has the ability to greatly compromise wound healing. There are at least seven ways to excise necrotic tissue. Nursing Care of Bed Sores 1- Autolytic debridement is the use of moist dressings to promote autolysis with the body's own enzymes. It is a slow process, but mostly painless. Nursing Care of Bed Sores 2- Biological debridement, or maggot debridement therapy, is the use of medical maggots to feed on necrotic tissue and therefore clean the wound of excess bacteria. Nursing Care of Bed Sores 3- Chemical debridement, or enzymatic debridement, is the use of prescribed enzymes that promote the removal of necrotic tissue. Nursing Care of Bed Sores 4- Mechanical debridement is the use of outside force to remove dead tissue. A quite painful method, this involves the packing of a wound with wet dressings that are allowed to dry and then are removed. This is also unpopular because it has the ability to remove healthy tissue in addition to dead tissue. Nursing Care of Bed Sores 5- Sharp debridement is the removal of necrotic tissue with a scalpel or similar instrument. 6- Surgical debridement is the most popular method, as it allows a surgeon to quickly remove dead tissue with little pain to the patient. Nursing Care of Bed Sores 7- Ultrasound-assisted wound therapy is the use of ultrasound waves to separate necrotic and healthy tissue.