Pressure Sores ppt

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Transcript Pressure Sores ppt

Claudia Mormino
Anatomy & Physiology P. 4
A pressure sore is caused
by pressure on an area
of the skin that interferes
with circulation.
 They can develop on
areas of the body that
rub together and
moisture collects (under
breasts, buttocks and
Pressure sores are mainly
caused in three ways:
friction (rubbing together),
shearing (skin stays in place
and muscles continue to
move in the opposite
direction), and prolonged
pressure (staying in the
same place for a long
period of time), which
interferes with the
circulation of that certain
 The
first sign of a pressure sore is a
change in skin color, which
usually turns to a red color.
 Pressure sores occur in four main
The skin is red, darkened or non blanchable (red skin that does turn
white when pressure is applied), that is still present thirty minutes
after pressure is relieved.
One should position off area and report it. Do not, by any means, try
to massage this area.
Observe every two hours and report any changes.
Blister like lesions may begin to appear, and the skin may be
Keep the area positioned off and report the need for dressing
Report any odors, drainage and change in size.
The skin tissue is destroyed and fatty
tissue may be involved.
 Infection and eschar (scab) may result.
 Continue to position off and report any
changes whatsoever.
Skin, and fatty tissue are destroyed and muscle and bone
may be involved.
Continue to position off and report changes.
In stage four, signs of systemic infection may appear. Be sure
to report any of the following changes: wound odor, pain,
elevated temperature, and confusion.
Stage Four
Stage Two
Stage Three
Stage One
Use these methods to prevent bedsores: make sure skin is clean and
dry; reposition every two hours; keep the linen dry, wrinkle free, and
clear of any objects that cause pressure; clean urine and feces from
skin ASAP; make sure clothing and shoes do not bind or constrict;
encourage the person to drink and have proper nutrition; massage
pressure points (prior to stage one).
 Some preventative devices include: bed cradles, heel and elbow
protectors, flotation devices, pillows, waterbeds, pressure mattresses,
and egg crate mattresses.
 The BEST way to prevent a bed sore is look for
and REPORT any changes in skin!!
Dugan , Diana. Successful Nursing Assistant Care. Second. Albuquerque, New Mexico:
Hartman Publishing, Inc., 2008. 320-337. Print.