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 After completing this chapter, you'll be able
to:
 discuss the significance of pressure ulcers as
a health care problem
 state the prevalence,etiology,incidence and
classification systems of pressure ulcers
 state how to complete a risk assessment tool
 Pressure ulcer prevention
 strategies for treating a patient with pressure
ulcers.
 “localized injury to the skin and/or
underlying tissue usually over a bony
prominence, as a result of pressure, or
pressure in combination with shear and/or
friction. A number of contributing factors are
also associated with pressure ulcers; the
significance of these factors is yet to be
elucidated.”
 Caused by pressure on area of skin
that interferes with circulation

 anarea of localised damage to the

skin and underlying tissue caused
by pressure, shear, friction and/or a
combination of these

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 Occur where bones come close to
the skin surface.
◦ toes, heels, ankles, knees
◦ hips, elbows, shoulders
◦ spine (especially tailbone area)
◦ ears, cheeks, collarbone area
◦ back of head

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 Can develop where areas of
body rub together and
moisture collects, especially
in obese People
◦ Under breasts
◦ Between folds of abdomen
◦ Between crease of buttocks
◦ Between thighs

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Risk factors include:
 Pressure  posture
 friction  cognition, psychological
 level of mobility status
 sensory impairment  previous pressure damage
 continence  extremes of age
 level of consciousness  nutrition and hydration
 acute, chronic and status
terminal illness  moisture to the skin
 Keep skin clean and dry
 Reposition Patients at
least every two hours
 Clean urine and feces
from skin as soon as
possible

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 Make sure clothing and
shoes do not bind or
constrict
 Encourage adequate
nutrition and fluids

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 Massage pressure points when
the resident is repositioned
 Report any changes in skin
condition immediately

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 Bed cradle
 Heel and elbow protectors
 cushions
 Pillows
 Water beds
 Alternating pressure
mattresses
 Air mattress

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 Tissue breakdown occurs in
stages
◦ Stage One - red, darkened or
non-blanchable skin, which is
still present 30 minutes after
pressure relieved

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 Tissue breakdown occurs in
stages
◦ Stage One (continued)
 position off area and report; do
not massage
 observe every 2 hours and
report changes to supervisor

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◦ Stage Two - addition of blister-
like lesions; skin may be broken
◦ Blister/Open Sore
 Tissue breakdown occurs in
stages
◦ Stage Three - skin tissue is
destroyed and fatty tissue may
be involved; infection and eschar
(scab) may result

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 Tissue breakdown occurs in
stages
◦ Stage Four - skin, fatty tissue
destroyed and muscle and bone
involved.
 continue prevention practices
 report any changes in area

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◦ Stage Four
 Damage to muscle or bone
 wound odor
 pain
 elevated temperature

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 Purposes

◦ Assist with
examinations
◦ Assist with procedures
◦ Prevent pressure on
skin for prolonged
periods of time
 Dorsal recumbent position
◦ flat on back
◦ knees slightly separated and
flexed
◦ feet flat on bed

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 Horizontal recumbent position –
supine
◦ flat on back
◦ legs slightly separated and
extended

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 Prone position
◦ flat on abdomen with head
turned to side
◦ arms at sides or flexed on either
side of head

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 Side lying position
◦ positioned on either side
◦ head in straight line with spine
◦ pillows used to support head,
back, arm, and leg

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 Lateral position
◦ positioned on either side
◦ bottom arm extended behind
back, top arm flexed in front of
body
◦ top leg slightly flexed

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 30 Lateral Reclined Position
◦ hips rotated 30 degrees
◦ pillow between knees
◦ pillow under arm for comfort and
to relieve pressure on elbow
◦ pressure relieved from sacrum
and hip

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 Fowler’s position
◦ sitting position in bed with head
elevated at 45-60 degree angle.
◦ knees slightly flexed
◦ position causes pressure on
sacrum and buttocks

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 Sim's position
◦ positioned on left side
◦ left arm extended behind body
◦ right arm flexed in front of body
◦ right leg flexed toward abdomen
◦ used for enema administration

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 Use postural supports as directed:
◦ Rolled blankets
◦ Pillows
◦ Rolled towels

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 Reposition at least every two hours
or as directed
◦ Eliminates pressure on bony areas
◦ Provides comfort
◦ Exercises muscles
◦ Moves joints
◦ Stimulates circulation

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 Coordinate lifting and moving
◦ Move on a certain count, usually
count of three
◦ Gain cooperation of resident
◦ Have residents help themselves
as much as possible

DHSR Approved Curriculum-Unit 14 33

 Coordinate lifting and moving
(continued)
◦ Use transfer belt (gait belt) when
appropriate
◦ When in doubt, always ask for
assistance from co-workers

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 Reasons for changing position
every two hours or as directed
◦ Promotes comfort
◦ Reduces pressure
◦ Increases circulation
◦ Exercises joints
◦ Promotes muscle tone

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 Body kept in good alignment with
head in straight line with spine
 Plastic or vinyl surface of chair

covered, with use of pressure-

relieving cushion preferred
 Pillows or soft blankets used for

support

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 Feet rest on floor or
footrest of wheelchair
 Hips positioned well

back in chair
 Weight shifting utilized

in between
repositioning

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