NILOFAR LOLADIYA MSN: OBGY Pressure ulcers (also known as pressure sores or bedsores) are injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin. They can happen to anyone, but usually affect people confined to bed or who sit in a chair or wheelchair for long periods of time. t is widely believed that other factors can influence the tolerance of skin for pressure and shear, thereby increasing the risk of pressure ulcer development. These factors are protein-calorie malnutrition, microclimate (skin wetness caused by sweating or incontinence), diseases that reduce blood flow to the skin, such as arteriosclerosis, or diseases that reduce the sensation in the skin, such as paralysis or neuropathy. The healing of pressure ulcers may be slowed by the age of the person, medical conditions (such as arteriosclerosis, diabetes or infection), smoking or medications such as anti-inflammatory drugs.

1. Mrs. Nilofar Loladiya
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2. An ulcer is a discontinuity or break in a bodily
membrane that impedes normal function of the
affected organ.
According to Robbins's pathology, "ulcer is the
breach of the continuity of skin, epithelium or
mucous membrane caused by sloughing out of
inflamed necrotic tissue."
WHAT IS AN ULCER?
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3. WHAT IS A PRESSURE ULCER?

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WHY PRESSURE ULCER DEVELOPS?

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HOW PRESSURE ULCER DEVELOPS?
Risk factors act on the soft tissues overlying
the bony prominences
This pressure exceeds normal capillary pressure
Reduced tissue perfusion
Ischemic Necrosis
PRESSURE SORE
Occlusion and tearing of small blood vessels

6. • A perpendicular load of
force exerted on a unit of area
(this could be a patients body
weight bearing down on a hip or sacrum).
• It causes local capillary occlusion (reduction in blood
supply) and compresses the structures between the
skin surface and bone.
Pressure
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7. • Pressure exerted by bony prominences on the body that stop
capillary flow to the tissues.
• Deprives tissues of oxygen and nutrients causing cell death.
• The damage can often be caused under the skin, but not
become obvious until the skin above it has broken down.
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8. • This is where pushing or pulling the skin means
more than one layer of skin slides against each
other and
• this can cause damage to these layers or they
may become detached from each other all
together.
Shearing
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9. Pressure and shear
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10. This is where two surfaces rub
together
• Skin and bed sheets, or a chair
cushion
• poorly fitting clothing
• manual handling aids.
Hot, moist skin is likely to
experience even more damage
from friction than more healthy
skin.
Friction
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Pressure, shear and Friction

12. • A pressure ulcer is an ulcer related to some form of
pressure and should not be confused with ulcers
relating to disease (like cancer), vascular flow
(venous or arterial) or neuropathy (like in persons
with diabetes)
• You should be able to see a “cause and effect”
relating to pressure with the ulcer.
– Redness or discoloration over a bony area related
to sitting or lying
– Redness or discoloration on the skin related to
pressure from a device or a wheelchair pedal
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13. How pressure injuries are
diagnosed ?
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Tools include skin visualization techniques and risk assessment tools
 The Braden Scale for Predicting Pressure Ulcer Risk, is a tool that was
developed in 1987 by Barbara Braden and Nancy Bergstrom. The
purpose of the scale is to assess a patient's risk of developing a
pressure ulcer.
 The Norton risk-assessment scale which was published in 1962. The
scale is used in the evaluation of pressure injury risk based on factors
such as mobility or physical condition.
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Most Common Sites
SUPINE POSITION

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Most Common Sites
PRONE POSITION

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Most Common Sites
LATERAL POSITION

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Most Common Sites

20. • Sacrum (tail bone)- 1st
-Semi-fowlers’ position
-Slouching in bed or chair
-higher risk in tube fed or
incontinent
Most Common Sites
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• Heels- 2nd
-Immobile or numb legs
-Leg traction
-Higher risk with PVD & DM
neuropathy
• Trochanter (hip bone)
-Side lying
• Ischium
(sitting erect bone)
-highest risk paraplegics

21. Medical devices and equipment
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22. STAGE 1:
Non-blanching.
• Grade 1:
• Non-blanchable erythema of
intact skin.
• Discolouration of the skin,
warmth, oedema, induration or
hardness.
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23. • Grey/purple hue to skin
• Induration present
• May be mushy or boggy
instead
• Often cannot visualize
damage until top layers of
skin sloughed
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STAGE 1:
Non-blanching.

24. • Grade 2:
• Partial thickness skin loss
• involving epidermis, dermis,
or both. The ulcer is
superficial and presents as an
abrasion or blister.
STAGE 2:
Broken skin
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STAGE 2:
Broken skin

26. • Grade 3:
• Full thickness skin loss
• involving damage to or
necrosis of subcutaneous
tissue that may extend down
to, but not through,
underlying fascia.
STAGE 3:
Sub-cutaneous
involvement
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STAGE 3:
Sub-cutaneous
involvement

28. • Grade 4:
• Extensive destruction, tissue
necrosis or damage to muscle,
bone of supporting structures,
with or without full thickness skin
loss.
STAGE 4:
Deep tissue
involvement
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29. Pressure Ulcer Stages
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Skin is
intact but
red.
Skin is broken
but there is no
depth to the
wound.
Skin is broken but there is
obvious depth to the wound,
fat tissue may be noted.
Skin is broken, muscle or
bone may be visible.
Severe tissue loss is
noted, wound may appear
as empty hole.
PRESSURE ULCER: Mrs Nilofar
Unstageable
Stage 1
Stage 4
Stage 3
Stage 2

30. • Unusual changes in skin color or texture
• Swelling
• Pus-like draining
• An area of skin that feels cooler or warmer to the
touch than other areas
• Tender areas
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Signs and Symptoms of a pressure injury
 ANY Changes in skin appearance should always be reported.
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Age, nutritional and Hydration status, including weight, weight loss, and
serum albumin levels, if indicated.
history of pre-existing chronic diseases (e.g., diabetes mellitus, acquired
immune deficiency syndrome, guillain-barré syndrome, peripheral and/or
cardiovascular disease)., Cancer (history of radiation therapy)
Client’s awareness of the sensation of pressure.
Assess for fecal and urinary incontinence.
Assess client’s ability to move (shift weight while sitting, turn over in bed,
move from the bed to a chair).
Assess for environmental moisture (excessive perspiration, high humidity,
wound drainage). Post-OP status

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Assess the amount of shear (pressure exerted laterally) and friction
(rubbing) on the client’s skin.
Assess the surface that the clients spend a majority of time on (mattress
for bedridden clients, cushion for clients in wheelchairs).
skin over bony prominences (sacrum, trochanters, scapulae, elbows,
heels, inner and outer malleolus, inner and outer knees, back of head).
tool for pressure ulcer risk assessment: Braden/Norton scale.
Assess the client’s level of pain,
Assess and stage the pressure ulcers: Measure the size of the ulcer, and
note the presence of undermining. Assess the condition of wound edges
and surrounding tissue.

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Nursing Diagnosis
Impaired Skin
Integrity
Possibly evidenced by
Destruction of skin layers.
Disruption of skin surfaces.
Drainage of pus.
Invasion of body structures.
Pressure ulcer stages
May be related to
Chronic disease state.
Extreme of ages.
Imbalanced nutritional state.
Impaired sensation.
Immobility.
Immunological deficit.
Incontinence.
Mechanical factors (friction, pressure, shear).
Moisture.
Poor circulation.
Pronounced body prominence.
Radiation.

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DESIRED OUTCOMES
• Client will experience healing of pressure ulcers
• Experiences pressure reduction.
• Absence of signs of inflammation
GOAL SETTING
• SHORT TERM: Client will get stage-appropriate wound care
• LONG TERM: Control risk factors for prevention of additional
ulcers in future

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SKIN INSPECTION
WOUND CARE
PATIENT/FAMILY INVOLVEMENT:
SKIN CARE
POSITIONING
COMFORT DEVICES
TREATMENT
SPECIAL NEEDS
NUTRITION

38. • Use the daily check charts to record on a daily basis that
every area has been checked: BRADEN/NORTON Scale
• If there is a pressure ulcer grade it accordingly.
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SKIN INSPECTION

39. • Wound care may be required based on severity
• Any patient with a pressure ulcer which is grade 2 or higher
should have a wound care plan.
• Dates and times should be set for the evaluation of pressure
ulcer and wound care plans so that regular updates can take
place.
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WOUND CARE

40. Encourage patients to maintain their NUTRITION:
– Meat, fish, or Protien alternatives.
– Fruit and vegetables. (Vit C)
– Milk and dairy products.
– Plenty of fluids stop the skin becoming dehydrated and can
reduce the risk of ulceration.
 LIFE STYLE CHANGES: SMOKING
 EXERCISE
CHECK SKIN at least once daily, or ask a carer to help.
A mirror will help to see hard-to-reach areas. Attend especially to
those areas where pressure is heaviest.
PATIENT/FAMILY INVOLVEMENT:
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41. • Avoid massaging bony parts of the body. This can cause addition
damage to skin which may already be delicate.
• Bed sheets should have no creases.
• Use warm (not too hot) water and mild soap to cleanse. Use a
moisturiser to avoid dry skin, and avoid cold or dry air.
• Skin should be cleansed as soon as Soiled. Using a soft cloth or
sponge should reduce friction.
• Control moisture-skin should be kept clean and dry (sweat).
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SKIN CARE

42. • A patient who is unable to reposition themselves
MUST have a repositioning plan.
• Plan on 2 hourly repositioning day and night.
Include 30° tilt on bed rest.
• Repositioning regimes need to:
– Minimise prolonged pressure on bony
prominences.
– Specify that repositioning takes place
regularly – even with pressure-relieving
devices in situ.
– Establish a means of recording when this
repositioning takes place
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POSITIONING

43. Do not use ring cushions
as these increase rather
than reduce pressure.
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COMFORT DEVICES

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Pain management-pressure injuries are painful and may require oral
medication for pain, especially around treatment times.
Barrier ointments should be used after incontinence
episodes to protect skin.
Oral antibiotics
Surgical repair:
Tissue Flap, Plastic Surgery
Debridement
Hyperbaric Oxygen Treatment
Topical Human growth factors
TREATMENT

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 Minimize pressure by utilizing edges,
frequent turning, and repositioning ever
2 hours.
 Minimize shear and friction to reduce
the damage to tissue.
 Avoid dragging; causes friction and
increases risk for skin damage

47. Case Study- Meet John
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PRESSURE ULCER: Mrs Nilofar
• John is diagnosed with Cerebral
Palsy, GERD, Diabetes insulin
dependent, and chronic
constipation. He is verbal, friendly
and has a good sense of
humor. He really loves going to his
day program.
• John has slow movements and
requires assistance to stand and
pivot. If lying in the bed he can roll
from side to side using the bed
rails.

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• When John becomes upset, he will wiggle out of his wheelchair onto the
floor when staff are not looking. On the floor he refuses to let the staff
help him back into his wheelchair.
• Today, John became very agitated when he could not go to his day
program. John wiggled out of his wheelchair onto the floor. Staff tried to
get him up, but he would slap at them and try to spit in their
face. Finally, the staff gave up and told John to let them know when he
was ready to get back in his chair.
• John sat in the floor for 3 hours. Finally, he asked for help and staff put
him in on the bed. HIs clothes were wet due to incontinence. As staff
provided hygiene and put on dry clothes, they noticed that John had two
areas of red skin: one on his right cheek and knee.
PRESSURE ULCER: Mrs Nilofar

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Incontinent of
Urine and/or stool
(wears briefs)
Requires DME for mobility​
Spends 4.5hours or more a
day in wheelchair
Fragile skin
Edema
related to Congestive
Heart Failure, and
/or Peripheral Artery
Disease.
Recent
change in weight
loss or gain​
Obesity
Anorexia
(Prader Willi's)
Behavior plan in place addressing
putting self in risky situations
(Refusing help off floor)
Unable to change body
position.​
(Cerebral Palsy, Stroke)​
PRESSURE ULCER: Mrs Nilofar

50. Apply
what
you've
learned
Name three interventions
that could have prevented
John from developing
pressure injury:
1.____________________
_______
2.____________________
_______
3.____________________
_______
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PRESSURE ULCER: Mrs Nilofar