COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Treatments POLICY NUMBER: 420 Effective Date: August 31, 2006 SUBJECT: PRESSURE SORE (DECUBITUS ULCER), PREVENTION AND TREATMENT 1. PURPOSE: A. Prevent pressure on any one area of the body for excessive lengths of time. B. Ensure the Individual s comfort. C. Prevent the spread of pathogenic microorganisms. D. Alleviate the Individual s fear and anxiety regarding the pressure sore that has already developed. Assessment: A. Pathophysiological concepts: 1. The stages of decubitus ulcer formation are: Stage I: Reddening of the skin not relieved by massage or by relief of the pressure believed to have caused it. Stage II: Superficial tissue damage involving skin breakdown. Stage III: Ulceration involving the dermis, which may or may not include the subcutaneous tissue; stage that produces serosanguineous drainage. Stage IV: Ulceration into the deep structures with invasion of the deep tissue or structures such as fascia, connective tissue, muscle or bone. 2. Decubitus ulcers are a potential problem of the immobile. Those particularly at risk are the elderly, the obese, the emaciated, and the paralyzed, whose mobility is impaired. Contributing factors to decubitus ulcer formation are continuous exposure of the skin to moisture, circulatory impairment, a break in the skin, inadequate nutrition, dehydration, inhibited sensory reception, and a lack of natural adipose tissue, which normally pads bony prominences. -1-
B. Assessment of the Individual 1. Assess the general condition of the individual. Note nutritional status, ability of the Individual to eat, ability of the Individual to chew food thoroughly, and amount of adipose (fat) tissue. Also note the mobility of the Individual, circulatory status in extremities, urinary and bowel continence, sensory perception in extremities and trunk, and level of hydration. 2. Assess the condition of the client. Note the stage or amount of tissue destruction. Assess the kind of care or treatment the area has received before hospitalization and the effectiveness of this care. 3. Assess the Individual s entire body to determine of other pressure sores are evolving. Assess the presence of the other pressure areas, the degree of redness, or lack of sensation. Check all bony prominences, folds of skin, and any area that might have received pressure due to the presence of tubes or drains. 2. COMMUNICATIVE ASPECTS OBERVATIONS: A. Document any reddened or whitened area, wither of which may indicate irritation. Give special attention to these areas by message, turning to keep the individual from lying on these areas, and continued observation to see that further damage does not occur. B. Observe for systemic conditions that my encourage the formation of pressure areas: impaired circulation, fever, alteration of cell function. Observe for adequate intake of foods and fluids to meet systemic needs. C. Check the Individual frequently for environmental factors that encourage the formation of pressure areas: wrinkled bed linen, objects in the bed, top bed linen applied tightly enough to restrict movement, and pressure or irritation from cast, adhesive, tubing, braces, traction, and other equipment. D. Observe any drainage from an open pressure sore. Note the type of drainage, amount, and frequency of appearance. If persistent, culture and sensitivity tests may be needed to determine causative and effective means to destroy them. Promptly report to the physician stages II through IV. E. The prescribed treatment of pressure sores is the responsibility of the physician. Preventive measure should be planned, implemented, and evaluated by the nursing staff. 3. EQUIPMENT: (Obtain all necessary equipment as indicated by Physician s Orders; e.g.) -2-
A. Obtain from Central Supply: (as required per treatment ordered) i.e. 1. 4x4 sterile gauze 2. Sterile basin 3. Sterile towel 4. Sterile, disposable water proof drapes 5. Sterile gloves 6. Culture swab (if ordered) 7. Sterile dressing forceps 8. Op-site as ordered 9. Disposable decubiti measuring device B. Obtain from Pharmacy: (treatment as ordered by M.D.) i.e. 1. Solution as ordered 2. Medication as ordered 3. Duo-derm as ordered 4. PROCEDURE: NURSING ACTION A. Pressure sores are caused by prolonged pressure which restricts blood flow to the area resulting in tissue breakdown. B. The desirable aspect in the treatment of pressure sores in prevention. Frequent turning, relief of pressure, and encouragement of circulation to the skin overlying the bony prominences is essential to prevention and early detection. Turn Individual at least every 2 hours or as ordered. Each time the Individual is turned, check the skin closely for signs of pressure areas. Gently massage bony prominences with lotion. Place the Individual in a variety of positions, including prone. Be sure the Individual s breathing is not restricted and is comfortable. C. There are a variety of methods for cleansing a pressure sore. Use the physician s preference as ordered. KEY POINTS A. Massage will promote the circulation to the area bringing needed nutrition to the cells and preventing destruction of skin cells to lack of adequate blood supply. B. Lying in the prone position is an excellent means of relieving pressure on the bony structure of the back. Each alteration of position causes a shift in the areas receiving pressure. Evenly distributing pressure over the body will prevent excess pressure on one area, resulting in a pressure sore. Use padding judiciously. Pillows are the best form of padding. C. The physician has the responsibility to prescribe appropriate treatment for the care of decubitus. -3-
D. The use of rubber or other protective materials may cause the Individual to perspire. The more desirable bed covering is a sheep skin, air mattress, floating pad, egg crate mattress, or other coverings designed to decrease pressure areas. D. Perspiration causes moisture buildup and further predisposes tissue breakdown. Special mattresses are designed to evenly distributing the body weight so that one area does not receive greater pressure than others. CAUTION: The use of these devices does not eliminate the need for turning the Individual or massaging the pressure area: E. Encourage bowel and bladder control if the client is able to cooperate. Offer the bedpan and urinal frequently. Change linen and give skin care as often as necessary to keep the Individual dry. E. Moisture from incontinence causes maceration of the skin. F. Encourage adequate intake. F. A deficient nutritional status is detrimental to the healing process. G. Wash hands carefully before and after caring for Individual s pressure sore. H. Take equipment to bedside. Explain procedure to the Individual and place Individual in a position of comfort, allowing for maximum access to the pressure ulcer. I. Obtain culture, if ordered by physician. J. *To culture a pressure ulcer 1. Clean surrounding skin with antiseptic 2. Clean gross debris, necrotic tissue and pus from wound with sterile water or saline 3. If possible, use sterile syringe to aspirate fresh, deep pus, or drainage 4. If unable to aspirate, insert sterile G. Hand washing has been shown to remove the majority of the pathogenic organisms present on the skin. Prevents spread of infection. H. For maximum effectiveness, enlist the Individual s cooperation and insure his comfort. I. Culture must be obtained before medicated treatment to insure adequate specimen. -4-
swab deep into wound. If anaerobic culture is ordered, obtain special culture swabs and transport media from laboratory. L. Using sterile technique and sterile gloves, perform the treatment as prescribed by the physician. L. To prevent cross contamination. M. Discard materials per. M. Be aware of contaminated and contraband items. 5. RECORDING: Record the time, procedure, solution used, any measurements taken, observations and Individual s response to treatment as per MHDS. Document all Individual education on the IDN notes. 6. NURSING IMPLICATIONS: Because pressure sores are a side of ill health rather than a disease, nurses caring for the Individual may feel considerable anxiety. Many sores, however, arise before hospitalization, or before any medical care has been given. In spite of a better understanding of the problems of pressure sores, there is still some reluctance to admit and discuss their presence and treatment. Nursing staff are encouraged to use outside Nurse Wound Care consultants for difficult or intractable cases of decubitus ulcer. *Reference* Infection Control and Applied Epidemiology, Principles and Practice, 1996-5-