Nursing care of pressure Injury in Intensive care Unit

1. SUKINAH BT MANIAH
CLINICAL NURSE SPECIALIST INTENSIVE CARE UNIT
HOSPITAL QUEEN ELIZABEH I I ,KOTA KINABALU .SABAH .

2. PRESSURE SORE AND SKIN CARE
• A pressure ulcer is considered an injury that is caused by unrelieved pressure
damaging the skin and underlying tissue.Unrelieved pressure on the skin
squeezes tiny blood vessels, which supply the skin with much needed nutrients
and oxygen. When the skin is starved for too long, the tissue dies and a pressure
ulcer form .

3. • Ulcers are common in 9% of the people in hospitals, 3 to 12% in nursing homes
and 3 to 14% of people being cared for at home. People transferred from
hospitals to nursing homes are particularly vulnerable, with 10 to 35% having
sores when they are admitted to the nursing home.

4. • Ulcers can lead to severe medical complications, including bone & blood
infections, infectious arthritis, holes below the wound that burrow into bone or
deeper tissues, and a scar carcinoma, a form of cancer that develops in scar tissue
.

5. • Ulcers form where the weight of the person’s body presses the skin against the
firm surface of a bed or chair. In people confined to bed, ulcers are most common
over theHip, Spine, Lower back, Shoulder blades, Elbows, Heels,Ears,Back of head

6. • This pressure from prolonged laying or sitting temporarily cuts off the skin’s
blood supply. This injures skin cells and can cause them to die. Unless the
pressure is relieved and blood flows to the skin again, the skin soon begins to
show signs of injury.At first, there may only be a patch of redness. If this red patch
is not protected from additional pressure, the redness can form blisters or open
sores.In severe cases, damage may extend through the skin and create a deep
crater that exposes muscle or bone.Muscle is even more prone to severe injury
from pressure than skin. A mild injury to the skin may cover a deeper, more
pronounced injury to the muscle and the bone .

7. • The pressure that causes ulcers does not have to be very intense. Pressure of less
than 25% the pressure of a normal mattress can lead to ulcers. Normally, our skin
is protected from being injured by this pressure because we move frequently,
even when we sleep.Although pressure on the skin is the main cause of ulcers,
other factors often contribute to the problem.

8. OTHERS FACTOR THAT CONTRIBUTED PI
• Decreased Movement: Ulcers are common in people who can’t move because of
various reasons such as severe arthritis, obesity, stroke and multiple sclerosis.
People who can move with little or no assistance have a lower risk of ulcers
because they can shift their weight occasionally.Decreased Sensation: Ulcers are
common in people who have neurological problems that decreased ability to feel
or verbally express pain or discomfort. Without these feelings, the person cannot
feel the effects of prolonged pressure on the skin .

9. OTHERS FACTORS THAT CONTRIBUTED PI
• Circulatory Problems: People with atherosclerosis, circulatory problems from long
term diabetes or localized swelling (edema) may be more likely to develop ulcers.
This is because the blood flow in their skin is weak even before pressure is
applied to the skin. People with anemia are also at risk because their blood
cannot carry enough oxygen to skin cells, even though circulation may be
normal.Poor Nutrition: Studies show that ulcers are more likely to develop in
people who don’t get enough protein, vitamins C & E, calcium or zinc.

10. OTHERS FACTORS THAT CONTRIBUTED PI
• Shearing & Friction: Shearing and friction causes skin to stretch and blood vessels
to kink, which can impair blood circulation in the skin. In a person confined to
bed, shearing & friction can occur when the person is dragged or slid across the
bed sheets. This can also occur when the head of the bed is raised more than 30
degrees. This increases shearing forces over the lower back & tailbone.Moisture:
Wetness from perspiration, urine or feces can make the skin too soft & more
likely to be injured by pressure.For this reason, people who can’t control their
bladders or bowels (incontinent) are at high risk of developing ulcers.

11. SYMPTOMS & SIGNS OF PRESSURE INJURY
• Stage 1 (earliest signs of skin damage) White people or people with pale skin
develop a lasting patch of red skin that does not turn white when you press it
with your finger. In darker skin, the patch may be more difficult to detect.

12. • Stage 2 The injured skin blisters or develops an open sore or abrasion that does
not extend through the full thickness of the skin. There may be a surrounding
area of red or purple discoloration, mild swelling & some oozing.

13. • Age: Elderly people, especially those over 85,
are more likely to develop ulcers because skin
usually becomes thinner with age. Also, as we
age, fat tends to shift away from the body
surface, where it acts as a cushion, to deeper
areas of the body.

14. • Stage 3 The ulcer becomes a crater that goes below the skin layer .
Stage 4 The crater deepens and reaches into a muscle, bone, tendon or joint

15. • Because broken skin is a prime spot for bacteria, ulcers are extremely vulnerable to
infection. This is especially true if the sore is contaminated by urine or feces. Signs of
infection in an ulcer can include
• Pus draining from the sore
• A foul smelling odor
• Tenderness, heat and increased redness in the surrounding skin
• Fever

16. • Health care experts believe that at least 50% of ulcers can be prevented by using
simple measures to relieve pressure and decrease the skin’s vulnerability to injury.
To help prevent ulcers in a person who is confined to a bed or chair, the health
care professional should create and follow a plan of care individualized to each
person.The plan may include these strategies:

17. • Relieve pressure on vulnerable areasChange the person’s position every two
hours when in bed and every hour when sitting in a chair. Use pillows to raise the
person’s arms, legs buttocks & hips. Relieve pressure onthe back with an egg-
crate foam mattress or a water mattress. Two types of beds, air-fluidize beds &
low-air-loss beds havebeen shown to reduce pressure ulcers by up to two thirds.
Use pillows or foam wedges to keep boney prominences suchas knees and ankles
from direct contact with each other. Teach chair bound people, who are able, to
shift their weightevery 15 minutes.Do not use donut devices!

18. • Reduce Shear & Friction
• Avoid dragging the person across the bed sheets. Either lift the person by using a lift sheet or
have the person use an overhead trapeze to briefly raise their body.
• Keep the bed free from crumbs and other particles that can rub and irritate the skin.
• Do not raise the head of the bed more than 30 degrees, unless they are eating in bed or the
doctor tells you otherwise.
• Use boots & elbow pads to reduce friction on heels and elbows. Elevate heels on pillows if
boots are not used.
• Wash the person gently. Avoid rubbing or scrubbing the skin and make sure they are
thoroughly dry.

19. • Encourage the person to eat wellThe diet should include enough calories, protein,
calcium, zinc and vitamin C & E. If the person cannot eat enough food, offer
nutritional supplements.Ask the doctor about ordering vitamin
supplements.Encourage daily exerciseExercise increases blood flow and speeds
healing. In many cases, even bedridden people can do stretches and simple
exercises.

20. • Keep the skin clean and dryClean the skin with a non-irritating, non-drying soap.
Avoid hot water. Dry skin well. Use absorbent pads to draw moisture away from
vulnerable areas.If the person is incontinent try to find ways to control or limit the
number of incontinent episodes. Toilet the person on a regular basis. Check for
wetness several times a day and provide incontinent care. Do not let a person sit
or lay in bed wet for long periods of time. Use topical moisture barriers. Lotion
skin well to prevent dryness and cracking. Do not massage over boney
prominences.

21. • Inspect the person’s skin at least once each dayEarly detection can prevent a
Stage I redness from becoming worse.Minimize irritation from chemicalsAvoid
irritating antiseptics, hydrogen peroxide, povidone iodine solution (Betadine) or
other harsh chemicals to clean or disinfect the skin.

22. PROGNOSIS
• In many cases, the outlook for ulcers is good.Prevention and early detection is
the ultimate situation that can be accomplished with PROGNOSISIn many cases,
the outlook for ulcers is good.Prevention and early detection is the ultimate
situation that can be accomplished with care and understanding by all. and
understanding by all.

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