PREVENTING PRESSURE SORE: WHAT NURSES SHOULD KNOW & WATCH OUT FOR

By: Angelyn O. Ragrag

I. PRESSURE SORE

Are lesions caused by unrelieved pressure on soft tissues overlying a bony prominence which reduces or completely obstructs the blood flow to the superficial tissues.

II. RISK FACTORS IN PRESSURE SORE DEVELOPMENT

Immobility Altered skin perfusion Decreased nutritional status

Impaired sensory perception or cognition

Friction & shear Increased moisture Advanced age/debilitation

STAGE I PRESSURE SORE

An area of nonblanchable erythema, tissue swelling, and congestion, and the patient complaints of discomfort.

STAGE II PRESSURE SORE

A break in the skin through the epidermis or dermis. A blister, abrasion, or shallow crater may be seen.

STAGE III PRESSURE SORE

It extends into the subcutaneous tissues. Clinically, a deep crater with or without undermining of adjacent tissues is noted.

STAGE IV PRESSURE SORE

It extends into the underlying structures including the muscle and, possibly, the bone.

IV. PRESSURE POINTS

Ear Acromion Process Ribs Greater trochanter Medial & lateral condyles Malleolus Back of the head Scapula Elbow Sacrum Heel

1) Assess pressure points. Nonblanchable erythema of intact skin, hardness, discoloration, or warmth of the skin may indicate skin ulceration.

2) Turn & reposition patient frequently.

3) Provide range of motion exercises(ROM) every 2 to 4 hours.

4) Use pressure-relieving or pressure-reducing devices such as an air mattress, gel-type floatation pads, wheelchair cushion, or specialized beds.

5) Moisturize skin sparingly. Avoid vigorous massaging.

6) Clean skin of feces or urine immediately.

7) Consult with nutritionist regarding dietary needs of the patient; Patient should be hydrated.

8) Closely monitor patients receiving vasopressors.

9) Avoid shearing forces. Turning sheets can be use to decrease shear & friction.

10) Measure the sore to determine its size & monitor if treatment is adequate.

11) Assist in wound care & debridement: autolytic, biological, chemical/enzymatic, or surgical.