Care and Prevention of Pressure Ulcers |
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Objective:
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To show the importance of individualizing turning and repositioning intervals for both comfort and prevention of pressure ulcers.
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Lesson:
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Pressure is the primary cause of pressure ulcers and an effective turning and repositioning program is an effective way to prevent pressure ulcers. Implementation of a turning and repositioning program is the key and effective monitoring of this by ALL staff can ensure its success.
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Consider all bed- or chair bound, or those whose ability to reposition is impaired, to be at risk for pressure ulcers.
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Skin care and Early Treatment
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1. Inspect the skin at least daily, and document assessment findings.
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2. Individualize bathing frequency. Use a mild cleansing agent. Avoid hot water with excessive friction.
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3. Assess and treat incontinence. When incontinence cannot be controlled, cleanse skin at the time of soiling, use a topical moisture barrier, and select under pads or briefs that are absorbent and provide a quick drying surface to the skin.
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4. Use moisturizers for dry skin. Minimize environmental factors leading to dry skin such as low humidity and cold air.
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5. Avoid massage over bony prominences.
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6. Use proper positioning, transferring, and turning techniques to minimize skin injury due to friction and shear forces.
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7. ALWAYS make sure to report and skin breakdown to the nurse or the BOM.
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8. Document your findings in the charting.
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9. Reposition bed bound clients every 2 hours, chair bound every hour.
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10. Teach chair fast patients that can reposition themselves to and do so every 15 minutes.
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11. Use lifting devices like Hoyer lifts or trapeze to move patients rather than dragging them.
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12. Use pillows or foam wedges to keep boney-prominences such as knees and ankles from direct contact with each other.
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13. Use devices that totally relieve pressure on the heels like a pillow or booties that will “float the heels’ off the bed.
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Pressure Ulcer Quiz:
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1. Which statement(s) are true about pressure ulcers?
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a. They are localized area of tissue damage
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b. They tend to occur at bony sites
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c. They are caused by prolonged pressure
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d. The patient/resident’s nutrition status affects the development of a pressure ulcer
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e. All the Above
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2. To prevent pressure ulcers from developing, which of the following steps should NOT be taken?
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a. Routinely observe high risk bony skin areas
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b. Turn clients only if they request it
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c. Minimize pressure
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d. Keep skin dry and clean
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3. A client is at risk for pressure ulcers when they are or have:
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a. Bed or chair bound immobility
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b. Poor nutritional status
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c. Moisture from urine and feces or wound drainage
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d. Sensory impairment such as stroke or dementia
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e. All the above
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4. Assess your clients for risk of pressure ulcers:
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a. The first time you see them then again if you think about it
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b. When there is a change in condition
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c. When the doctor orders it only
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d. Every shift
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e. Both b and d
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5. Which of the following repositioning techniques are key to preventing pressure?
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a. Turning bed bound patient at least every 2 hours
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b. Floating heels
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c. Padding between bony prominences
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d. Repositioning chair bound patients every hour
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e. All the above
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Answer key: |
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1. E
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2. B
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3. E
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4. E
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5. E
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