Pressure Ulcer

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Pressure Ulcer
  Pressure Ulcer Diagnostic Evaluation   1.    No testing is usually indicated. 2.   Wound cultures are usually inaccurate due to bacterial contamination and colonization, but may be done to guide antibiotic therapy when signs of infection are present. Therapeutic Interventions   1.   Pressure must be relieved and maceration, friction and shearing forces avoided for  wound healing to take place. 2.    Normal saline is used for routine cleansing once to several times daily depending on the amount of wound drainage, unless a protective dressing is used. 3.   Wet to dry dressings may be used to assist with mechanical debridement. 4.   Debridement of devitalized tissue may be necessary using scissors and scalpel following sterile technique. 5.   Protective wound dressings may be used to minimize disruption of migrating fibroblasts and epithelial cells and to provide moist, nutrient rich environment for healing. Pharmacologic Interventions   1.   Debriding enzymes may be used for stage III to IV ulcers; may damage healthy tissue and are not appropriate for hard eschar. 2.   Topical antibiotics may be used to treat signs of local wound infection. 3.   Analgesics are usually needed, particularly 30 to 60 minutes before wound care. Nursing Interventions   1.   Monitor for signs of local infection (erythema around edges, foul odor, purulent exudates, poor healing) as well as sepsis (fever, cellulites around wound, increased pain, decreased blood pressure, tachycardia, altered level of consciousness).  2.   Assess size of pressure sore weekly in response to therapeutic measures; document the largest diameter, not just the surface diameter, and document the greatest depth. 3.   Monitor pain level and response to pain medication; in unresponsive patient, look for agitation, tachycardia and increased blood pressureto indicate pain. 4.   Use pressure0 reducing surface to help prevent pressure sores, but they are not effective in treating established pressure sores. 5.   Avoid elevating head of the bed more than 30 degrees to prevent shearing force as the patient slides downward against mattress. 6.   Encourage activity and ambulation as much as possible. 7.   Turn and reposition patient every 2 hours. 8.   Bathe patient as needed with a bland soap, rinse, and blot dry with a soft towel. 9.   Lubricate skin at least twice daily with a bland cream or gel, especially over pressure points. 10.   Employ bowel and bladder program to prevent incontinence. 11.   Avoid plastic coverings and poorly ventilated chair or mattress surfaces. 12.   Ensure that high protein, nutritious diet is provided, utilize supplements as necessary and ensure adequate fluids to hydrate skin. 13.   Clean pressure sore, as directed or per protocol; use normal saline or  prescribed solution, irrigate as necessary to remove exudates, but do not disrupt healing tissue. 14.   Teach diet rich in protein, iron, and vitamin C to aid in full healing.
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