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Nursing Care of Bed Sores

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					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.

				
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