Decubitus Ulcer (bedsores, pressure sore) Associated With Infection : Tretament and Nursing Management
Bedsore is a special type of ulcer caused by impaired blood supply and tissue nutrition resulting from prolonged pressure over bony or cartilaginous prominences. The skin overlying the sacrum and hips is most commonly involved, but bed sores may also be seen over the occiput areas, elbow, heels, ankles, scapula, medial condyle of tibia and head of fibula. They may occur most readily in aged, paralyzed, debilitated and unconscious patient.
Factors contributing for bed sores
Immobility, decreased sensory perception, decreased tissue perfusion and nutritional status, friction, increased moisture of the skin Poor nourishment, and obesity (patient have large amount of poorly vascularized adipose tissue)
Clinical manifestation
If a pressure area is noted, the nurse notes its size and location and use grading system to describe its severity.
Stage I
Pressure ulcer is an area of Erythema, tissue swelling and congestion and with patient complaining discomfort, the skin temperature is elevated because increase vasodilatation. The redness progresses to a dusky, cyanotic blue gray appearance, which is the result of skin capillary occlusion weakening of subcutaneous tissue.
Stage II
Pressure ulcer exhibits a break in the skin through the epidermis include the dermis, and also necrosis of the skin wills occurre.
Stage III
Pressure ulcer extend to sub cutaneous tissue
Stage IV
Ulcer extend in to the under lying structure including muscle possibly the bone. The skin lesion may represent only the tip of ice berg” between small surface ulcer may overlie a large under lining area.
The appearance of pus or foul odor is suggestive sign of infection
Nursing diagnosis
Impaired skin integrity related to any of the contributing factors.
Nursing goal
The major goals of nursing may include relief of pressure; improve mobility, improved nutritional status and tissue perfusion.
Nursing interventions
1. Relieving pressure – frequent change of position by using variety of pads & supportive device to prominent area or if it is possible use flotation or water bed.
2. Improve mobility – patient is encouraged to remain active, passive and active exercise help to increase muscular skin and vascular tone.
3. Improve sensory perception- by increased awareness of self
4. Improve tissue perfusion- exercise and repositioning will improve tissue perfusion
5. Improve nutritional status- high protein and iron will be given to increase the level of hemoglobin
6. Reduce friction - Make the bed daily & as needed to give comfort
7. Minimizing moisture- soiled skin should be washed with mild soap and water and then dry with soft towels and if the patient is in continent urine catheterization will be done
8. Maintain skin integrity by offering bath
9. Teach the family about frequent position and the important of skin hygiene.
10. Give the prescribed antibiotic
11. Dress the wound accordingly
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