How to prevent pressure ulcer.

PRESSURE ULCER (BED SORE)
Terminally ill patients are at risk of developing pressure. This article is a guide for care givers to have some knowledge of the factors that causes pressure ulcer and take measures to prevent the development of pressure ulcer. 

HOW DOES PRESSURE ULCER DEVELOP?

When the skin and body tissues are compressed for a very long period against bony areas and hard surfaces, such as the mattress, it causes localized damage to the tissues. The extent of damage can be very superficial such as redness or can be deep where the damage involves muscle tissues, and tendons and bones may be exposed. 


AREAS THAT ARE PRONE TO DEVELOP PRESSURE ULCERS















WHAT FACTORS CONTRIBUTE TO THE DEVELOPMENT OF PRESSURE ULCERS?

1.       The primary cause of pressure ulcer is prolonged pressure that is applied on soft tissues over bony prominences and hard surfaces such as the mattress.

2.       Contributing factors are

a.       Immobility

b.       Decreased activity

c.       Decreased sensory perception

d.       Moisture

e.       Friction  and shearing

f.        Poor  nutrition

g.       Advanced age

FACTORS THAT CONTRIBUTE TO PRESSURE ULCERS IN PATIENTS WHO ARE TERMINALLY ILL

1.       Fragile skin condition

2.       Older age

3.       Decreasing fluid and food intake

4.       Altered sensation

5.       Poor general physical condition

6.       Lean body constitution

7.       New pain site or unrelieved pain

8.       Shortness of breath and inability to lie flat related to shortness of breath (patients normally are in sitting position to relieve shortness of breath.   This causes continuous pressure on the buttocks or sacrum)

10.   Decreased mobility

WHY IS IT IMPORTANT TO PREVENT THE DEVELOPMENT OF PRESSURE ULCERS?

        Pressure ulcers have negative effect on patient, family and caregivers. It can lead to social isolation and a feeling of burden to others.

        Patient’s quality of life is affected as there is a change in body image, pain, odour and drainage, and it also affects the patient financially.

HOW TO PREVENT THE DEVELOPMENT OF PRESSURE ULCERS?

1.       IDENTIFY PERSONS AT RISK AND APPLYING PREVENTIVE MEASURES

·         We need to first identify persons who are at risk in developing pressure ulcers. Please refer to the factors that contribute to the development of pressure ulcers (as mentioned above). Having identified the factors, assist us to take preventive measure accordingly.

2.       MINIMIZING PRESSURE

•  Minimize pressure on body tissues by turning the patient every 2 hours or less.  Lying longer than 2 hours will lead to skin breakdown. If this pressure is not relieved it will cause damage to the tissues.
• For persons who cannot be turned fully on the side, make frequent position changes and support the back and legs with pillows.
• Pressure on bony prominences e.g. the ankle bone, can be reduce by elevating that part using a small pillow that is placed under the calves.
• When positioning an ill person on the side, do not position him directly on the hip bone. This position will cause direct pressure on the hip bone.  Position him/her at about 30˚ angle.
• When a person is in a sitting position , encourage him/her to shift her position every 15 minutes.
• Give enough pain killers to ensure adequate pain control if the pain is causing the patient to refuse turning. 
• Use distribution mattresses or devices such as the ripple mattress to help relieve pressure. Even though ripple mattresses are used, the patient will also need to be turned every 2 hours. Using ripple mattress alone, will not help prevent the development of bedsores, but is helpful when a patient is not cooperative. e.g. a patient who goes back into the back position half an hour after turning without the care giver being aware of it.
• Medical devices, such as the oxygen tubing can also cause ulcers. Therefore, routinely check the area for signs of pressure and re-position the tubing to relief pressure.
  

3.       MINIMIZE OR ELIMINATE FRICTION OR SHEARING

• Do not drag the patient’s body when moving patient in bed or chair. Place a thick sheet underneath the patient and use it to lift the patient.
• If you are nursing an ill patient using the hospital bed, ensure that the head of bed is below 30˚ (unless while eating or patient has difficulty in breathing). Anything more than 30˚ can cause friction and shearing to the sacrum and buttocks.
• When a patient is sitting in a chair, advise him/her to sit at 90˚ angle. Slouching can cause friction and shearing.
• When using a bedpan, roll the patient to the side to insert and remove the bedpan. Pushing and pulling bedpan in and out can cause friction.
  

4.       MANAGE MOISTURE

• Patients who are incontinent and using adult pampers, have the risk of developing ulcers in the private areas as the urine and faeces causes the skin to be easily damaged. If the patient is not able to inform you that they have urinated, check the pampers every 2 hours or as needed. As soon as the patient urinates or open bowels (pass motion), clean the skin gently with mild cleanser. Avoid scrubbing the skin to prevent injury to the skin. 
• After cleaning and drying, apply skin barriers such as creams and ointments which are available in the pharmacy.
• Check for broken skin or fungal infection and consult the attending doctor or nurse to get it treated as soon as possible.
• Always keep skin folds dry.
  

TIPS

If the patient is using adult pampers, you can use a spray bottle to rinse after cleaning the private area with soap. Make sure the soiled pampers is not removed before you rinse with a spray bottle so the dirty water is absorbed by the soiled pampers.

5.       MAINTAIN ADEQUATE NUTRITION AND HYDRATION

• Nutritional deficiency and dehydration causes decreased muscle mass leading to decrease padding on bony prominences.
• Provide adequate nutrition according to individual needs and wishes.
• Provide high-protein and high-calorie supplements as well as fluids
  

NOTE
When a patient has reached end-of-life, they are no longer able to eat or drink to maintain adequate nutrition, therefore, the caregivers will need to take the other measures such as minimize pressure, friction and shearing and managing moisture to prevent the development of pressure ulcers. 

THESE ARE GUIDELINES IN PREVENTION OF PRESSURE ULCER. EACH INDIVIDUAL PATIENT IS DIFFERENT AND MAY NEED A DIFFERENT APPROACH. PLEASE CONSULT YOUR ATTENDING NURSE FOR ADVICE IF YOU FACE ANY DIFFICULTIES

REFERENCES
1. Anderson, J., Langemo, D.K., Sulkowski, K. & Ayello, E.A. (2007). Evidence-Based Nursing Care Guidelines: Medical-Surgical Interventions (1st Ed.). St. Louis, Missouri, USA: Elsevier Mosby. Retrieved from Mosby’s Nursing Consult.

2.  Bryant, R.A & Nix, D.P.  (2012).Acute & Chronic Wounds: Current Management Concepts. (4th Ed.) . St. Louis, Missouri, USA: Elsevier Mosby. Retrieved from Mosby’s Nursing Consult.

3.  Churbock, C. (2011). Pressure Ulcer: Risk Assessment and Prevention. Retrieved from Mosby’s Nursing Skills.

4.  Meiner, S.E. (2010). Gerontologic Nursing (4th Ed.). St. Louis, Missouri, USA: Elsevier Mosby. Retrieved from Mosby’s Nursing Consult.



 

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