How frequently? How should pressure ulcer care planning based on identified risk be used? What items should be in our bundle? What additional resources are available to identify best practices for pressure ulcer prevention? Some of the factors that make pressure ulcer prevention so difficult include: It is multidisciplinary: Nurses, physicians, dieticians, physical therapists, and patients and families are among those who need to be invested.
It is multidimensional: Many different discrete areas must be mastered. It needs to be customized: Each patient is different, so care must address their unique needs.
It is also highly routinized: The same tasks need to be performed over and over, often many times in a single day without failure. It is not perceived to be glamorous: The skin as an organ, and patient need for assessment and care, does not enjoy the high status and importance of other clinical areas. The pressure ulcer bundle outlined in this section incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment. Standardized pressure ulcer risk assessment.
Care planning and implementation to address areas of risk. The challenge to improving care is how to get these key practices completed on a regular basis. Some of the advantages of these clinical pathways are to: Reduce variation and standardize care. Provide efficient, evidence-based care. Improve outcomes. Educate staff as to best practices. Improve care planning. Facilitate discussion among staff. This color-coded tool can be used by the hospital unit team in designing the new system, as a training tool for frontline staff, and as an ongoing clinical reference tool on the units.
This tool can be modified, or a new one created, to meet the needs of your particular setting. If you prepared a process map describing your current practices described in section 2 , you can compare that to desired practices outlined on the clinical pathway.
Practice Insights Given the complexity of pressure ulcer preventive care, develop a clinical pathway that describes your bundle of best practices and how they are to be performed. Return to Contents 3. These include: Identify any pressure ulcers that may be present. Assist in risk stratification; any patient with an existing pressure ulcer is at risk for additional ulcers. Determine whether there are other lesions and skin-related factors predisposing to pressure ulcer development, such as excessively dry skin or moisture-associated skin damage MASD.
Identify other important skin conditions. Provide the data necessary for calculating pressure ulcer incidence and prevalence. J Wound Ostomy Continence Nurs ; Incontinence associated dermatitis a consensus.
J Wound Ostomy Continence Nurs ;34 1 Usual practice includes assessing the following five parameters: Temperature. Moisture level. Skin integrity skin intact or presence of open areas, rashes, etc. Practice Insights Take advantage of every patient encounter to evaluate part of the skin. Always remind staff performing comprehensive skin assessments of the following helpful hints: Don't forget to wash your hands before doing the skin assessment and after and to use gloves.
Make sure the patient is comfortable. Minimize exposure of body parts while you are doing the skin assessment.
Ask for assistance if needed to turn the patient in order to examine the patient's backside, with a particular focus on the sacrum. Look at the skin underneath any devices such as oxygen tubing, indwelling urinary catheter, etc. Make sure to remove compression stockings to check the skin underneath them.
Action Steps Assess whether your staff know the frequency with which comprehensive skin assessment should be performed. Action Steps Assess the following: Are results of the comprehensive skin assessment easily located for all patients? Are staff comfortable reporting any observed skin abnormalities to physicians and nurse managers?
Practice Insights Have a standardized place to record in the medical record the results of the skin assessment. A checklist or standardized computer screens with drop-down prompts with key descriptors of the five components of a minimal skin assessment can help capture the essential information obtained through the patient examination.
Communication among licensed and unlicensed members of the health care team is important in identifying and caring for any skin abnormalities. Some places have found it effective to use a diagram of a body outline that an unlicensed heath care worker can mark with any skin changes they might see while bathing or performing care activities. Be especially concerned about the following issues: Finding the time for an adequate skin assessment: As much as possible, integrate the comprehensive skin examination into the normal workflow.
But remember that this is a separate process that requires a specific focus by staff if it is to be done correctly. Determining the correct etiology of wounds: Many different types of lesions may occur on the skin and over bony prominences. In particular, do not confuse moisture-associated skin changes with pressure ulceration.
If unsure about the etiology of a lesion, ask someone else who may be more knowledgeable. Using documentation forms that are not consistent with components of skin assessments: Develop forms that will facilitate the recording of skin assessments. Having staff who do not feel empowered to report abnormal skin findings: Communication among nursing assistants, nurses, and managers is critical to success. If communication problems exist, staff development activities targeting cross-level communication skills may be in order.
Nurses and managers may need to solicit and positively reinforce such reporting if nursing assistants do not have confidence in this area. Develop methods to facilitate communication. One example would be a sticky note pad that includes a body outline, patient name, and date. Aides would mark down any suspicious lesions and give the note to nurses. Tools An example of a notepad to be used for communication among nursing assistants, nurses, and managers can be found in Tools and Resources Tool 3C, Pressure Ulcer Identification Notepad.
Encourage staff to: Ask a colleague to confirm their skin assessments. Having a colleague evaluate the skin assessment will provide feedback as to how they are doing and will help correct documentation errors.
Perform skin assessments with an expert. Consider having an expert or nurse from another unit round with unit staff quarterly to confirm findings from the comprehensive skin assessment. Ask for clarification when they are unsure of a lesion.
Take advantage of the local wound care team or other staff who may be more knowledgeable. Use available resources to practice their ability to differentiate the etiology of skin and wound problems. Resources This slide show illustrates how to perform a skin assessment: www. Practice Insights A full-body skin inspection does not have to mean visualizing all aspects of the patient in the same time period.
When applying oxygen, check the ears for pressure areas from the tubing. If the patient is on bed rest, look at the back of the head during repositioning. When checking bowel sounds, look into skin folds. When positioning pillows under calves, check the heels and feet using a hand-held mirror makes this easier. When checking IV sites, check the arms and elbows. Examine the skin under equipment with routine removal e. Each time you lift a patient or provide care, look at the exposed skin, especially on bony prominences.
Action Steps Ask yourself and your team: Do you have a policy about who is responsible for the risk assessment on admission and thereafter? Does everyone know the process for performing risk assessment? Pressure ulcer risk assessment is essential for a number of reasons: It aids in clinical decisionmaking. Many clinicians are not skilled in identifying patients at risk for developing pressure ulcers. Use of a standardized risk assessment helps to direct the process by which clinicians identify those at risk and quantify the level of this risk.
It allows the selective targeting of preventive interventions. Pressure ulcer prevention is resource intensive. Resources should be targeted toward those at greatest risk who would most-benefit. It facilitates care planning. Care plans focus on the specific dimensions that place the patient at greatest risk.
It facilitates communication between health care workers and care settings. Workers have a common language by which they describe risk. Action Steps Ask yourself and your team: Do the unit staff understand why they are doing the risk assessment? Are unit staff communicating the risk assessment results to all clinicians who need to know?
Presence of a pressure ulcer: All patients with an existing pressure ulcer should be considered at-risk for an additional ulcer. Prior Stage III or IV pressure ulcers: When Stage III or IV ulcers close through a process of scar tissue formation and eventual epithelialization, the resulting skin is not normal as it lacks its former tensile strength and is very prone to break down again.
Hypoperfusion states: Patients who are not perfusing vital organs as a result of conditions such as sepsis, dehydration, or heart failure are also not adequately perfusing the skin. Minimal amounts of pressure may then cause ulceration. Peripheral vascular disease: Because of the limited blood supply to the legs, these patients are predisposed to pressure ulcers of the feet, particularly the heels.
Diabetes: Patients with diabetes have consistently been shown to be at increased risk of pressure ulcers. Smoking: Smoking interferes with oxygen delivery. Smoking is associated with recurrence of pressure ulcers postsurgery and likely increases risk of new pressure ulcers.
Restraint use: Patients with physical restraints have limited mobility in addition to having pressure applied at the site of the restraints. Chemical restraints with resulting sedation may lead to rapid decline in mobility. Spinal cord injury: Immobility, incontinence, and impaired sensation may combine to place these patients at exceptionally high risk.
The level and completeness of the spinal cord injury is critical in this determination. Make sure your clothes are not increasing your risk of developing pressure ulcers: Avoid clothes that have thick seams, buttons, or zippers that press on your skin. DO NOT wear clothes that are too tight. Keep your clothes from bunching up or wrinkling in areas where there is any pressure on your body.
After urinating or having a bowel movement: Clean the area right away. Dry well. Ask your provider about creams to help protect your skin in this area. If You Use a Wheelchair.
Make sure your wheelchair is the right size for you. Have your doctor or physical therapist check the fit once or twice a year. If you gain weight, ask your doctor or physical therapist to check how you fit your wheelchair. If you feel pressure anywhere, have your doctor or physical therapist check your wheelchair. This will take pressure off certain areas and maintain blood flow: Lean forward Lean to one side, then lean to the other side If you transfer yourself move to or from your wheelchair , lift your body up with your arms.
If your caregiver transfers you, make sure they know the proper way to move you. When You Are in Bed. When you are lying on your side, put a pillow or foam between your knees and ankles.
When you are lying on your back, put a pillow or foam: Under your heels. Or, place a pillow under your calves to lift up your heels, another way to relieve pressure on your heels. Under your tailbone area. Under your shoulders and shoulder blades. Under your elbows.
It puts pressure on your heels. Never drag yourself to change your position or get in or out of bed. Dragging causes skin breakdown. Get help if you need moving in bed or getting in or out of bed. If someone else moves you, they should lift you or use a draw sheet a special sheet used for this purpose to move you. Change your position every 1 to 2 hours to keep the pressure off any one spot.
Sheets and clothing should be dry and smooth, with no wrinkles. Remove any objects such as pins, pencils or pens, or coins from your bed.
DO NOT raise the head of your bed to more than a 30 degree angle. Or depending on the your medical condition, the bed should at least be elevated to the lowest degree to prevent injury. When lying on your side, a 30 degrees position should be used.
There are a variety of treatments available to manage pressure sores and promote healing, depending on the severity of the pressure sore. These include:. This page has been produced in consultation with and approved by:.
Bedbugs have highly developed mouth parts that can pierce skin. In most cases, we do not know what causes birthmarks. Most are harmless, happen by chance and are not caused by anything the mother did wrong in pregnancy. If you are bitten or stung by an insect or animal, apply first aid and seek medical treatment as soon as possible.
A blister is one of the body's responses to injury or friction. Severe blushing can make it difficult for the person to feel comfortable in social or professional situations. Content on this website is provided for information purposes only. Information about a therapy, service, product or treatment does not in any way endorse or support such therapy, service, product or treatment and is not intended to replace advice from your doctor or other registered health professional.
The information and materials contained on this website are not intended to constitute a comprehensive guide concerning all aspects of the therapy, product or treatment described on the website.
All users are urged to always seek advice from a registered health care professional for diagnosis and answers to their medical questions and to ascertain whether the particular therapy, service, product or treatment described on the website is suitable in their circumstances. The State of Victoria and the Department of Health shall not bear any liability for reliance by any user on the materials contained on this website.
Skip to main content. Home Skin. Pressure sores. Actions for this page Listen Print. Summary Read the full fact sheet. On this page. Grades of pressure sores Complications of pressure sores Risk factors for pressure sores Preventing pressure sores Warning signs of pressure sores Treatment for pressure sores Where to get help.
Pressure sores are graded to four levels, including: grade I — skin discolouration, usually red, blue, purple or black grade II — some skin loss or damage involving the top-most skin layers grade III — necrosis death or damage to the skin patch, limited to the skin layers grade IV — necrosis death or damage to the skin patch and underlying structures, such as tendon, joint or bone.
Complications of pressure sores Untreated pressure sores can lead to a wide variety of secondary conditions, including: sepsis bacteria entering the bloodstream cellulitis inflammation of body tissue, causing swelling and redness bone and joint infections abscess a collection of pus cancer squamous cell carcinoma.
Risk factors for pressure sores A pressure sore is caused by constant pressure applied to the skin over a period of time. Other risk factors for pressure sores include: immobility and paralysis — for example due to a stroke or a severe head injury being restricted to either sitting or lying down impaired sensation or impaired ability to respond to pain or discomfort.
0コメント