Nursing How To’s: Pressure Ulcer Care
It’s free cut and instead of hanging out at the cafeteria with some of her classmates, Josie chose to go to the library and do advanced reading since they will be having a graded recitation tomorrow and she’s pressured to have high scores. She’s scanning through her books when she comes about gruesome pictures of late staged pressure sores. More intrigued than disgusted, she opens the book to the page and reads on all while wondering what role nurses should play when dealing with these cases and how they will be able to help patients prevent developing such.
Interventions to prevent Pressure Ulcer
Mild Risk (Score 15-18)
- Turning and re-positioning patient at least every 2 hours
- Maximal re-mobilization
- Protection of heels and other bony prominences (occiput, ears,scapula, spinous processes, shoulders, elbows, iliac crest, sacrum/coccyx, ischial tuberosity, trochanters, knees, malleous, and toes)
- Managing moisture, nutrition, friction, and shear (elevate head of bed no more than 30 degrees)
- Supportive measures for pressure reduction, if bed or chair bound
- Nutrition consult when patient’s Braden score is 18 or less
Moderate risk (Score 13-14)
- Mild Interventions
- Specific turning and re-positioning schedule
- Wedge devices for lateral positioning
- Pressure redistribution support surface
- Manage nutrition
High Risk (Score 10-12)
- Mild and moderate interventions
- Increased frequency of turning, including small shifts of weight
Very High Risk (Score 9 and below)
- Mild, moderate, and high interventions
- Reassessment every shift
Interventions based on Pressure Sore Stage
Stage I (Goal: Protect the skin and remove the cause)
- Change position in bed or chair every two hours
- Assess need for support surface.
- Maintain head of bed at 30 degrees or less, unless contraindicated.
- Use draw sheet for re-positioning.
- Do not massage reddened areas.
- Elevate heels off bed with pillow or protective boots/splints.
- Avoid positioning on affected area
Stage II (Goals: Protect the skin and manage exudates; closure and regrowth of skin)
- Manage exudates/moisture: Apply wound dressing; change every 3–5 days and prn.
- None-to-light exudates: Ointment to affected area, need MD order; a thin wound dressing
- Moderate-to-heavy exudates: Adhesive wound dressing or a non-adhesive wound dressing secured in place
Stage III & IV (Goals: Protect and keep wound clean; manage exudates; and reduce wound size
- Manage exudates/moisture: Apply a wound dressing to create a moist wound environment, which assists in autolytic debridement of wounds covered with necrotic tissues
- None-to-light exudates: Apply a thin wound dressing or gel
- Moderate-to-heavy exudates: Adhesive or non-adhesive wound dressing secured in place; selection of dressing influenced by size and location of the pressure ulcer; a rope or sheet wound dressing may be needed in specific situations or to pack the wound; change every 1–3 days and prn, cover.
Sources:
- http://www.rehabnurse.org/pdf/GeriatricsPressureUlcer.pdf
- http://www.medscape.com/viewarticle/565606_3
Liane Clores, RN MAN
Currently an Intensive Care Unit nurse, pursuing a degree in Master of Arts in Nursing Major in Nursing Service Administration. Has been a contributor of Student Nurses Quarterly, Vox Populi, The Hillside Echo and the Voice of Nightingale publications. Other experience include: Medical-Surgical, Pediatric, Obstetric, Emergency and Recovery Room Nursing.
