Transcript Prevention of Pressure Ulcers

Unit 14
Prevention of Pressure Ulcers
Nurse Aide I Course
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Prevention Of Pressure Ulcers
Introduction
As a direct care giver, the nurse
aide will be the key team member in
the prevention of pressure ulcers.
Knowledge of the relationship
between blood supply and tissue
destruction, as well as the skills
necessary to properly position
residents to minimize the effects of
pressure, are essential.
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14.0 Discuss pressure ulcers and
methods used to prevent them.
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Pressure Ulcers
• Previously called decubitus ulcers or
bed sores
• Caused by pressure on area of skin
that interferes with circulation
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14.1 Identify areas where pressure
ulcers most frequently occur.
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Pressure Ulcers
(continued)
• Occur where bones come close to
the skin surface.
–toes, heels, ankles, knees
–hips, elbows, shoulders
–spine (especially tailbone area)
–ears, cheeks, collarbone area
–back of head
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Pressure Ulcers
(continued)
• Can develop where areas of
body rub together and moisture
collects, especially in obese
residents
–Under breasts
–Between folds of abdomen
–Between crease of buttocks
–Between thighs
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14.1.2 List the methods used to
prevent the formation of
pressure ulcers.
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Methods Used To Prevent
Pressure Ulcers
• Keep skin clean and dry
• Reposition residents at least
every two hours
• Keep linen dry and free of
wrinkles and objects that
cause pressure to the skin
• Clean urine and feces from
skin as soon as possible
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Methods Used To Prevent
Pressure Ulcers
(continued)
• Make sure clothing and
shoes do not bind or
constrict
• Pat skin dry when bathing;
never scrub
• Encourage adequate
nutrition and fluids
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Methods Used To Prevent
Pressure Ulcers
(continued)
• Massage pressure points when the
resident is repositioned
• Report any changes in skin condition
immediately
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14.1.3 Identify devices used to prevent
pressure ulcers.
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Preventive Devices Used To Prevent
Pressure Ulcers
•
•
•
•
•
•
Bed cradle
Heel and elbow protectors
Flotation pads or cushions
Pillows
Water beds
Alternating pressure
mattresses
• Eggcrate mattresses
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Pressure Ulcers: Stages Of Tissue
Breakdown And Treatment
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14.1.4 Review the four stages of tissue
breakdown and identify the
nurse aide’s role in assisting
with treatment.
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Pressure Ulcers: Stages Of Tissue
Breakdown And Treatment
• Tissue breakdown occurs in stages
–Stage One - red, darkened or nonblanchable skin, which is still
present 30 minutes after pressure
relieved
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Pressure Ulcers: Stages Of Tissue
Breakdown And Treatment
(continued)
• Tissue breakdown occurs in stages
–Stage One (continued)
• position off area and report; do
not massage
• observe every 2 hours and report
changes to supervisor
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Pressure Ulcers: Stages Of Tissue
Breakdown And Treatment
(continued)
• Tissue breakdown occurs in stages
–Stage Two - addition of blister-like
lesions; skin may be broken
• position off area at all times
• report need for dressing changes
• report odor, drainage, any change
in size
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Pressure Ulcers: Stages Of Tissue
Breakdown And Treatment
(continued)
• Tissue breakdown occurs in stages
–Stage Three - skin tissue is
destroyed and fatty tissue may be
involved; infection and eschar
(scab) may result
• continue prevention practices
• report any changes in area
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Pressure Ulcers: Stages Of Tissue
Breakdown And Treatment
(continued)
• Tissue breakdown occurs in stages
–Stage Four - skin, fatty tissue
destroyed and muscle and bone
involved.
• continue prevention practices
• report any changes in area
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Pressure Ulcers: Stages Of Tissue
Breakdown And Treatment
(continued)
• Tissue breakdown occurs in stages
–Stage Four (continued)
• report any signs of systemic
infection, including but not limited
to:
–wound odor
–pain
–elevated temperature with
confusion
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14.2 Identify three purposes for
positioning residents.
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Positioning
• Purposes
–Assist with
examinations
–Assist with
procedures
–Prevent pressure on
skin for prolonged
periods of time
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14.2.1 Discuss the various types of
positions and suggest reasons
for use.
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Types Of Positions
• Dorsal recumbent position
–flat on back
–knees slightly separated and flexed
–feet flat on bed
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Types Of Positions
(continued)
• Horizontal recumbent position –
supine
–flat on back
–legs slightly separated and
extended
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Types Of Positions
(continued)
• Prone position
–flat on abdomen with head turned to
side
–arms at sides or flexed on either
side of head
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Types Of Positions
(continued)
• Side lying position
–positioned on either side
–head in straight line with spine
–pillows used to support head, back,
arm, and leg
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Types Of Positions
(continued)
• Lateral position
–positioned on either side
–bottom arm extended behind back,
top arm flexed in front of body
–top leg slightly flexed
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Types Of Positions
(continued)
• 30 Lateral Reclined Position
–hips rotated 30 degrees
–pillow between knees
–pillow under arm for comfort and to
relieve pressure on elbow
–pressure relieved from sacrum and
hip
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Types Of Positions
(continued)
• Fowler’s position
–sitting position in bed with head
elevated at 45-60 degree angle.
–knees slightly flexed
–position causes pressure on
sacrum and buttocks
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Types Of Positions
(continued)
• Sim's position
–positioned on left side
–left arm extended behind body
–right arm flexed in front of body
–right leg flexed toward abdomen
–used for enema administration
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14.3 Discuss moving, turning,
positioning and lifting residents.
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Moving, Turning, Positioning
And Lifting
• Good body mechanics necessary
–Prevents injury to resident
–Protects nurse aide from injury
–Good body alignment promotes
comfort for resident
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Moving, Turning, Positioning
And Lifting
(continued)
• Safety major consideration
–Get help if needed
–Receive directions from supervisor
regarding any restrictions for
positioning or movement
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Moving, Turning, Positioning
And Lifting
(continued)
• Safety major consideration (continued)
–Protect and secure any special
equipment being used by the
resident prior to movement (e.g.,
drainage tubes).
–Elevate bed to comfortable working
level
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Moving, Turning, Positioning
And Lifting
(continued)
• Safety major consideration
(continued)
–Protect skin from friction
• roll when possible
• lift with assistance
• prevent sliding
• use turning sheet
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Moving, Turning, Positioning
And Lifting
(continued)
• Use postural supports as directed:
–Rolled blankets
–Pillows
–Rolled towels
–Footboards
–Bed cradles
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Moving, Turning, Positioning
And Lifting
(continued)
• Reposition at least every two hours or
as directed
–Eliminates pressure on bony areas
–Provides comfort
–Exercises muscles
–Moves joints
–Stimulates circulation
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Moving, Turning, Positioning
And Lifting
(continued)
• Coordinate lifting and moving
–Move on a certain count, usually
count of three
–Gain cooperation of resident
–Have residents help themselves as
much as possible
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Moving, Turning, Positioning
And Lifting
(continued)
• Coordinate lifting and moving
(continued)
–Use transfer belt (gait belt) when
appropriate
–When in doubt, always ask for
assistance from co-workers
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14.4 Demonstrate the procedure for
moving the resident up in bed.
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14.5 Demonstrate the procedure for
moving a resident up in bed using
a turning sheet.
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14.6 Demonstrate the procedure for
positioning a resident on side.
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14.7 Discuss repositioning the resident
in a chair or wheelchair.
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Repositioning Resident In Chair
Or Wheelchair
• Reasons for changing position
every two hours or as directed
–Promotes comfort
–Reduces pressure
–Increases circulation
–Exercises joints
–Promotes muscle tone
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Repositioning Resident In Chair
Or Wheelchair
(continued)
• Body kept in good alignment with
head in straight line with spine
• Plastic or vinyl surface of chair
covered, with use of pressurerelieving cushion preferred
• Pillows or soft blankets used for
support
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Repositioning Resident In Chair
Or Wheelchair
(continued)
• Feet rest on floor or
footrest of wheelchair
• Hips positioned well back
in chair
• Weight shifting utilized in
between repositioning
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