Pressure ulcers and traumatic wound carePreventing, staging, and treating wounds

Pressure ulcers and traumatic wound care
Preventing, staging, and treating wounds

Pressure ulcer care

As their name implies, pressure ulcers result when pressure—applied with great force for a short period or with less force over a longer period—impairs circulation, depriving tissues of oxygen and other life-sustaining nutrients. This process damages skin and underlying structures. Untreated, the ischemic lesions that result can lead to serious infection.

Most pressure ulcers develop over bony prominences, where friction and shearing force combine with pressure to break down skin and underlying tissues. Common sites include the sacrum, coccyx, ischial tuberosities, and greater trochanters. Other common sites include the skin over the ears, vertebrae, scapulae, elbows, knees, and heels in bedridden and relatively immobile patients. (See Pressure points: Common sites for ulcers.)

Successful treatment of pressure ulcers involves relieving pressure, restoring circulation and, if possible, resolving or managing related disorders. Typically, the effectiveness and duration of the treatment depend on the characteristics of the pressure ulcer. (See Staging pressure ulcers, pages 452 and 453.)

Ideally, prevention is the key to avoiding extensive therapy. Preventive measures include ensuring adequate nourishment and mobility to relieve pressure and promote circulation.

When a pressure ulcer develops despite preventive efforts, treatment includes methods to decrease pressure, such as frequent repositioning to shorten the duration of the pressure and the use of special equipment to reduce the intensity of the pressure. Treatment may also involve the use of special devices, such as beds, mattresses, mattress overlays, and chair cushions. (See Pressure reduction devices, page 454.) Other therapeutic measures include reducing risk factors and using topical treatments, wound cleaning, debridement, and moist dressings to support wound healing.

The nurse usually performs or coordinates treatments according to facility policy. The procedures described here address cleaning and dressing pressure ulcers. Always follow the “Standard Precautions” guidelines of the Centers for Disease Control and Prevention.

Equipment and preparation

Hypoallergenic tape or elastic netting ♦ piston-type irrigating system ♦ two pairs of gloves ♦ normal saline solution, as ordered ♦ sterile 4″ × 4″ gauze pads ♦ selected topical dressing (moist saline gauze, hydrocolloid, transparent, alginate, foam, or hydrogel) ♦ linensaver pads ♦ impervious plastic trash bag ♦ disposable wound-measuring device ♦ sterile cotton swabs ♦ optional: 21G needle and syringe, alcohol pad, pressure-reducing device, turning sheet

Assemble the equipment at the patient’s bedside. Cut the tape into strips for securing dressings. Loosen the lids on cleaning solutions and medications for easy removal. Make sure that the impervious plastic trash bag is within reach.


♦ Before performing any dressing change, wash your hands and review the principles of standard precautions.

Cleaning the pressure ulcer

♦ Provide privacy and explain the procedure to the patient to alleviate his fears and promote cooperation.

♦ Position the patient in a way that maximizes his comfort while allowing easy access to the pressure ulcer site.

♦ Cover the bed linens with a linensaver pad to prevent soiling.

♦ Open the normal saline solution container and the piston syringe. Carefully pour normal saline solution into an irrigation container to avoid splashing. (The container may be clean or sterile, depending on facility policy.) Put the piston syringe into the opening provided in the irrigation container.

♦ Open the packages of supplies.

♦ Put on gloves to remove the old dressing and expose the pressure ulcer. Discard the soiled dressing in the impervious plastic trash bag to avoid contaminating the sterile field and spreading infection.

♦ Inspect the wound. Note the color, amount, and odor of drainage and necrotic debris. (See Tailoring wound care to wound color, page 455.) Measure the perimeter of the wound with the disposable wound-measuring device (a square, transparent card with concentric circles arranged in a bull’seye fashion and bordered with a straightedge ruler).

♦ Using the piston syringe, apply full force to irrigate the pressure ulcer to remove necrotic debris and help to decrease bacteria in the wound.

♦ Remove and discard the soiled gloves and put on a fresh pair.

♦ Insert a gloved finger or a sterile cotton swab into the wound to assess wound tunneling or undermining. Tunneling usually signals extension of the wound along fascial planes. Gauge the

depth of the tunnel by determining how far you can insert your finger or the cotton swab.

Aug 18, 2016 | Posted by in NURSING | Comments Off on Pressure ulcers and traumatic wound carePreventing, staging, and treating wounds

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