8.3 Pressure Ulcer Prevention and Management

Pressure ulcers are a serious concern in nursing care, affecting patient comfort and health. This section covers prevention, assessment, and management strategies, emphasizing the importance of early intervention and comprehensive care.

Nurses play a crucial role in preventing and treating pressure ulcers. From regular repositioning to proper wound care, these skills are essential for maintaining skin integrity and promoting healing in vulnerable patients.

Pressure ulcers: Definition and risk factors

Understanding pressure ulcers

• Pressure ulcers occur as localized injuries to skin and/or underlying tissue, typically over bony prominences, resulting from prolonged pressure or pressure combined with shear and/or friction
• Prolonged, unrelieved pressure on skin impairs blood flow leads to tissue damage
• Braden Scale assesses pressure ulcer risk considering factors (sensory perception, moisture, activity, mobility, nutrition, friction/shear)
• Early identification of at-risk patients through regular skin assessments and risk factor evaluation promotes prevention

Risk factors for pressure ulcer development

• Immobility limits patient's ability to relieve pressure on vulnerable areas
• Poor nutrition compromises skin integrity and healing processes
• Incontinence exposes skin to moisture and irritants increases susceptibility
• Altered sensory perception reduces ability to feel discomfort and change position
• Advanced age decreases skin elasticity and resilience
• Chronic conditions (diabetes, vascular disease) impair circulation and healing
• Certain medications (steroids) thin skin and slow wound healing

Preventing pressure ulcers: Strategies and evidence

Positioning and support surfaces

• Regular repositioning of immobile patients every 2 hours redistributes pressure
• Proper positioning techniques utilize supportive devices (pillows, foam wedges)
• Specialized mattresses (alternating pressure, low air loss) reduce pressure and shear forces
• Pressure-redistributing support surfaces (specialized cushions, overlays) significantly reduce pressure ulcer risk

Skin care and moisture management

• Keep skin clean and dry using pH-balanced cleansers maintains skin integrity
• Apply moisturizers prevent dryness and maintain skin elasticity
• Implement incontinence management (prompt cleaning, moisture barriers) protects skin from irritants
• Use breathable materials for bedding and clothing reduces skin moisture

Nutrition and hydration

• Ensure adequate protein intake supports tissue repair and maintenance
• Provide sufficient calorie intake meets energy needs for healing
• Maintain proper hydration promotes skin elasticity and nutrient delivery
• Consider nutritional supplements (vitamin C, zinc) enhance wound healing processes

Patient and caregiver education

• Teach proper repositioning techniques empowers patients and caregivers
• Demonstrate skin inspection methods enables early detection of skin changes
• Explain importance of nutrition and hydration in pressure ulcer prevention
• Provide information on pressure-relieving devices and their proper use

Pressure ulcer assessment and staging

NPUAP staging system

• Stage 1: Non-blanchable erythema of intact skin
• Stage 2: Partial-thickness skin loss with exposed dermis
• Stage 3: Full-thickness skin loss
• Stage 4: Full-thickness skin and tissue loss with exposed deeper structures (muscle, tendon, ligament, cartilage, bone)
• Unstageable: Full-thickness skin and tissue loss obscured by slough or eschar
• Deep tissue pressure injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to underlying soft tissue damage

Wound assessment techniques

• Evaluate wound size using standardized measurement methods (length, width, depth)
• Assess presence of undermining or tunneling indicates extent of tissue damage
• Examine exudate characteristics (amount, color, consistency) provides information on wound status
• Evaluate surrounding tissue for signs of infection or deterioration
• Use photographic documentation enables objective monitoring of wound progression
• Implement consistent use of standardized assessment tools ensures accurate tracking of healing

Wound care management: Principles and nursing role

TIME framework and wound cleansing

• TIME framework guides comprehensive wound management:
  • Tissue management removes non-viable tissue
  • Inflammation and infection control promotes healing environment
  • Moisture balance optimizes wound healing
  • Edge of wound assessment ensures proper wound closure
• Select appropriate cleansing solutions (normal saline, wound cleansers) based on wound characteristics
• Employ proper irrigation techniques remove debris without damaging healthy tissue

Debridement and dressing selection

• Autolytic debridement uses body's own enzymes to break down necrotic tissue
• Enzymatic debridement applies topical enzymes to selectively remove non-viable tissue
• Mechanical debridement physically removes dead tissue (wet-to-dry dressings, wound irrigation)
• Surgical debridement involves sharp removal of non-viable tissue by a healthcare professional
• Choose appropriate dressings based on wound characteristics:
  • Hydrocolloids provide moist environment for dry wounds
  • Alginates absorb excess exudate in heavily draining wounds
  • Foam dressings manage moderate exudate and provide cushioning
  • Antimicrobial dressings (silver, iodine) control bacterial burden in infected wounds

Pain management and infection control

• Administer analgesics before wound care procedures reduces patient discomfort
• Implement non-pharmacological pain management techniques (relaxation, distraction)
• Monitor for signs of wound infection (increased exudate, odor, surrounding erythema)
• Obtain wound cultures when infection suspected guides appropriate antibiotic therapy
• Maintain clean technique during dressing changes prevents introduction of pathogens

Patient education and interdisciplinary collaboration

• Teach patients proper dressing change techniques promotes wound healing and prevents complications
• Educate on signs of wound complications enables early detection and intervention
• Provide guidance on lifestyle modifications (smoking cessation, nutrition) supports overall healing
• Collaborate with wound care specialists for complex cases ensures optimal treatment plans
• Consult dietitians for nutritional support enhances wound healing processes
• Involve physical therapists in mobility and positioning strategies prevents further tissue damage