CASEY STEVENS

TREATMENT OF PRESSURE ULCERS

OBJECTIVESReview the general information and pathophysiology of pressure ulcers

Discuss a clinical scenario and nursing diagnosis associated with pressure ulcer findings

Identify the treatments and interventions needed for pressure ulcers.

• Understand the diet needed for a patient with pressure ulcers. • Identify medications used to help with pain and help with the healing

of pressure ulcer • Discuss any surgical procedures and why they are needed.• Describe any dressings• Identify alternative wound dressing agents• Discuss the effects of wound cleansing on pressure ulcers. • Discuss any other interventions

NCLEX style questions

References

PATHOPHYSIOLOGY• Ischemic ulcers resulting from unrelieved pressure, shearing

forces, friction and moisture.

• Location and the depth of involvement describe pressure ulcers. They can be found over the scapula, ischium, sacrum, trochanter, heels, and posterior iliac spine.

• Pathophysiologic factors underlying pressure ulcers include fever, anemia, infection, ischemia, hypoxemia, hypotension, malnutrition, neurologic disease, decreased lean body mass, and increased metabolic demands.

• Pressure ulcers are staged or graded as follows:

• Stage 1• Stage 2• Stage 3• Stage 4

STAGE 1 • Still in tacked,

beginning of skin breakdown, reddened area that does not blanch

STAGE 2• Opening of the

skin, high risk for infection

STAGE 3• A lot deeper

and thick, close to the muscle

STAGE 4• Down to the bone

CLINICAL SCENARIO• Female patient who was 77 years of age

• Had a stage 2 pressure ulcer

• Problem factors:

• Decreased mobility• Malnourished • Fall risk

Nursing diagnosis: Impaired skin integrity related to physical immobility, mechanical factors, altered circulation, and skin irritants.

TREATMENTS AND INTERVENTIONS

• Diet

• Medications

• Surgical procedures

• Dressings

• Alternative wound dressing agents

• Wound cleansing

• Other interventions

DIET• Protein intake:

• Protein is essential to help the body make new tissue. When we don’t eat enough protein our tissues become weak and when damaged, heal very slowly

• Adjust protein intake based on:• Stage• Number• Size of wounds

• If you choose 3 of the 4 food groups (dairy, grain, protein and vegetables) at each meal, and one or two of the food groups as snacks, you are helping your body get the nutrients it needs to heal pressure ulcers and achieve better health.

MEDICATIONS• Antibiotics:

• Pressure sores that are infected and do not respond to any other interventions may be treated with topical or oral antibiotics.

• Pain management:

• Topical or oral pain medication may be appropriate.

• Interventions that may reduce pain include the use of nonsteroidal anti-inflammatory drugs-such as ibuprofen, Motrin, and Advil.

SURGICAL PROCEDURES

• Operative repair of pressure ulcers is an option for patients with stage III and stage IV ulcers that do not respond to conservative wound care.

• Surgical procedures include direct closure, skin grafting, and free flaps.

• Based on a case study, pressure ulcer have had a 87% healing rate after surgical procedures.

DRESSINGS• Dressings that maintain a moist environment promote wound

healing

• Should keep ulcer bed continiously moist and keep the surrounding intact skin dry

• Types of dressings include:

• Hydrocolloid- occlusive or semi-occlusive dressings composed of materials such as gelatin and pectin

• Transparent film- adhesive semi-permeable dressing that allows water to vaporize and cross barrier, retains moisture

• Hydrogel- water based gel that impregnates the gauze, or sheet dressings

• Foam- available as pads, sheets, and pillow dressings that provide moist environment and thermal insulation

• Saline-moistened gauze- for deep wounds, especially if tunneling

ALTERNATIVE WOUND DRESSING AGENTS

• Medihoney

• A strong and growing evidence base practice• Includes several large scale randomized controlled

studies • Studies have shown that medihoney dressings are

effective on hard-to-heal wounds in addition to helping to debride wounds and keeping wound beds clean of necrotic tissue.

• Medihoney works in the presence of wound fluid, blood, and tissue, thus promoting an optimal healing environment.

WOUND CLEANSING

• Wound cleansing refers to the application of fluid to the pressure ulcer to aid removal of debris and contaminants

• Irrigation is the preferred method of cleansing and normal saline is the recommended fluid

OTHER INTERVENTIONS

• Maggot therapy

• Maggot therapy may be useful as an added treatment when stages III and IV pressure ulcers are not healing

• Maggots are ideal because they feed on dead and infected tissue without harming healthy tissue.

• Maggots are mixed into a wound dressing and the area is covered with gauze. After a few days, the dressing is taken off and the maggots are removed.

NCLEX: QUESTION 1

A male client is on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?a.    Inadequate vitamin D intakeb.    Inadequate protein intakec.    Inadequate massaging of the affected aread.    Low calcium level

NCLEX: QUESTION 2Pressure ulcers are most often associated with patients who

A. Are immobilized

B. Psychiatric diagnosis

C. Experience respiratory distress

D. Need close supervision for safety

REFERENCESUnbound, Medicine (2011, April 28) Pressure Ulcers, retrieved fromhttp

://nursing.unboundmedicine.com/nursingcentral/ub/view/Diseases-and-Disorders/73697/all/pressure_ulcer

Osborne, K.S., Wraa, C.E. &Watson, A.B. (2010). Medical –Surgical Nursing: Preparation for Practice. Upper Saddle River, NJ: Pearson.

DynaMed. (2008, March 8).Pressure sores. Lucas, MD :EBSCO Publishing. Retrieved September 30, 2012 from http://web.ebscohost.com.ezproxy.hsc.usf.edu/dynamed/detail?sid=9135de7d-ba74-41c2-9ceb-39f977a55d9c%40sessionmgr4&vid=8&hid=13&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#db=perc&AN=2009866440

DynaMed. (2008, March 8).Pressure ulcers. Dugaw, MD :EBSCO Publishing. Retrieved from September 02, 2012 fromhttp://web.ebscohost.com.ezproxy.hsc.usf.edu/dynamed/delivery/printcitation?expand=sec-Treatment&viewtype=standalone&vid=3&hid=13&sid=9135de7d-ba74-41c2-9ceb-39f977a55d9c%40sessionmgr4&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#db=dme&AN=116231&anchor=anc-933148971