CARE OF BEDSORE OR PRESSURE POINTS
A SIMPLE NURSING PROCEDURE.
DEFINITION:
Decubitus ulcers, also known as pressure sores or decubiti, are ulcerated or sloughed area of tissue subjected to pressure from lying on mattress or sitting on a chair for prolonged period of time resulting in the slowing of circulation and finally death of tissues.
Pressure points are those that bear weight, so that the skin over them is subject to pressure. The pressure points in the supine position are back of the head (occiput), scapula, sacral region, elbow and heels. In a prone position, the pressure points are ears, cheek, acromian processes, breasts ( in the female), genitalia (in the males), knee and toes.
Purposes :
To promote relaxation and comforts.
To relieve muscular tension.
To stimulate circulation.
Equipment :
Bath blanket to provide warmth.
Bath towel.
Skin application (skin lotion or talcum powder)
Clients susceptible to Bed Sores :
1. Actually ill clients, whose general condition is rapidly deteriorating.
2. Elderly bedridden clients who make very little movements in bed.
3. Obese clients.
4. Very thin and emaciated clients, having very little subcutaneous tissue to pad the bony prominences.
5. Sedated clients who have suffered spinal cord injuries.
6. Paralysed clients, who have suffered spinal cord injuries.
7. Neurologic clients with lack of sensations that they cannot feel any irritation of the skin.
8. Oedematous clients especially those with oedema of the sacrum and buttocks.
9. Malnourished clients with protein and vitamin deficiencies.
10. Agitated clients in restraints.
11. Surgical clients with limited movements.
12. Clients on complete bed rest or with limited movements.
Prevention of Pressure Sores :
1. Identification of clients who are are particularly prone to the development of decubitus ulcer.
2. Daily examination of the decubitus prone clients for redness, discoloration or blisters on the pressure points and they should be reported and treated immediately.
3. Keep the clients clean and dry.
4. Change the positions of the clients every 2 hours so that another body surface bears weight.
5. Keep the clients skin well lubricated to prevent cracking by using powder.
6. Protect the damaged skin. Damaged skin can be further irritated and macerated by urine, faeces, sweat etc.
7. Provide the client with adequate fluids and with a nourishing diet that is high in protein and vitamins.
8. Attend to the pressure points as often as necessary to stimulate circulation.
9. Call assistance and lift the clients before giving and taking bedpans.
Signs and Symptoms of Pressure Sores :
The early symptoms of pressure sore are redness, tenderness, discomfort and smarting. The area becomes cold to touch and insensitive. There is local oedema. Later the area becomes blue, purple or mutted. Due to continued pressure, the circulation is cut off, the gangrene develops and the affected area is sloughed off.
Treatment of the Decubitus Ulcer :
Despite of the conscientous use of preventive measures, certain clients because of their extremely debilitated condition, to develop pressure sores. Moist and poorly nourished tissue is a good medium for growth of pathogenic bacteria. The following step are taken by the nurses:
1. Report to the sister in-charge and the physician the early symptoms of a bedsores so that steps may be taken as early as possible to prevent further damage.
2. Whenever possible, take off the pressure from the decubitus ulcers by placing the client on pillows or foam cushions or change the position of the client.
3. Prevent the ulcerated area from becoming infected. Infection will retard healing of an ulcer.
4. A cleaning agent is used to clean the ulcerated area. Eg. Normal saline.
5. Apply the possible measures for the healing of the wound.
6. If slough is present, clean the area thoroughly twice a day with hydrogen peroxide diluted with distilled water.
Procedure :
Steps :
1. Assess whether the patient has risk factors for skin impairment.
Rationale
To determine the need for back care.
2. explain the patient the purpose of back care.
Rationale
To reduce anxiety.
3. draw the curtains or keep screen around the bed.
Rationale
To provide privacy.
4. raise the bed level to convenient working height and lower the side rails.
Rationale
Prevents unnecessary stain on the nurses back.
5. remove the patient gown or untie the back ties and slip the back portion of the gown towards the shoulders.
Rationale
Expose the entire back for the massage.
6. position the patient on his/her side with the back towards the nurse.
Rationale
For performance of the procedure.
7. apply hand first to the sacral area, massaging in circular motion, stroke upward from buttocks, I.e, shoulder massage over scapulas with smooth stroke continue.
8. knead skin by grasping tissue between thumb and finger knead upward along one side of spine from buttocks to shoulders and around nape of the neck. Stroke downward toward sacrum repeat along other side of back.
Rationale
Kneading increases circulation to muscles, continuous motion is soothing and relieves muscle tension.
9. end massage with long stroking movements and tell patient you are ending back rub.
Rationale
Long stroking is most soothing of massage movements.
10. if patient is lying inside turn him to opposite side and massage other hip.
Rationale
Promotes circulation of entire back.
11. remove soiled towel and wash hands.
Rationale
Promotes infection control.