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Файл:Clinical nursing practice. Study aid for foreign students of medical university
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contact with the ring's inner edge and cut off the micro-circulation to the
tissues which were over the “hole” of the ring.
3. The location, size and grade of any sores as wounds.
Location It can be useful to draw the sores on body outlines (see
fig. 9) which can be added to the person's nursing assessment record.
Fig. 9. The areas of possible ulcers on the body
The assessment can be dated and the size and grade of any tissue
damage recorded alongside the site.
This can then be used as a tool for evaluating progress or deterioration in the condition of the tissues over time. The frequency of reassessment will depend on the sores, but generally weekly measurements
are found to be useful.
Size. There are obvious limitations in measuring sores. For example,
measurement is often only possible of the surface area of damage, which is
relatively easy. Assessment of the volume of damaged tissue is more difficult and even techniques which allow for the measurement of cavity size
cannot provide an estimate of the degree of damage to underlying deep
structures. Despite these limitations, measurements of surface area damage
and cavity size do provide some objective measure against which to judge
improvement or deterioration. Assessment of the base of the wound cavity
can be based on the identification of necrotic or devitalized tissue and the
amount of slough and exudate.
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Wound recordings can have a motivating effect for both nurses and
clients. Some patients/clients can find visible evidence of improvement
encouraging. This can be particularly important for sores which are healing and where the person may not easily be able to see the area of damage
for themselves, for example where there are sacral sores.
Sores (and other wounds) can be measured in a number of ways:
1. By recording at least two diameters of the wound with a ruler or
dividers. The surrounding skin may need to be marked so that subsequent
measurements relate to the same axes. Ideally, the same observer should
carry out the measurement on each occasion.
2. By mapping the wound. The wound can be traced on a transparent
sheet, polythene bag or tracing paper. Subsequent recordings can be visually compared with previous tracings to assess change.
3. By using a wound-sizing grid. This can be at a fairly sophisticated
level using a plan meter, or more simply, using a grid drawn onto transparent film, such as old X-ray film, as a ready-reckoner.
4. By wound casting. Casting can be used to visualize the shape of the
wound as well as providing a measure of the volume of tissue damage. Silicone polymer foam can be used to make casts. Although it is an expensive
way of measuring the wound, if silicone foam is being used to treat the
wound, the serial treatment casts can be saved and act as a comparative
record of shape and size.
Grade. Pressure sores are wounds and can be classified accordingly.
In addition, a number of grading systems designed specifically for pressure
sores have been identified. Table 12 shows the grading system developed
by David et al. Assessing the grade of sore can be useful in describing the
state of the sore and helping to identify the most appropriate wound management strategies.
5. The absence or presence of wound infection. Most pressure sores
with any degree of tissue loss will be colonized by bacteria. Erythema and
swelling of over 1 cm are usually present at the margins of infected
wounds. Infected sores with sloughing tend to produce greenish slough
with pus and an offensive odour. Wound swab cultures need to be inter-
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preted with caution as the infecting organisms are often commensal organisms found on the skin (for example, Staphylococci and Streptococci) or in
the gut flora (such as Escherichia coll).
Table 12
Pressure sore grades
Grade
Description
1
(a) Where the skin is likely to break down (red, black and blistered areas)
(b) Healed areas still covered by a scab
2
Superficial break in the skin
3
Destruction of the skin without cavity (full skin thickness)
4
Destruction of the skin with cavity (involving underlying tissues)
6.5. PLANNING THE PREVENTION AND TREATMENT
OF PRESSURE SORES
Prevention. The definitive method for preventing pressure sores has
still to be invented. Within any nursing setting, a range of prevention strategies can be found. Sometimes these are the result of deliberate protocols
or guidelines, and sometimes they have been adopted through tradition,
routine, personal preferences or simply their availability. However we
have developed our approaches to care, it is important that we reflect on
why we use them, whether they are based on a sound rationale or research
findings and whether they are effective.
Exercise. Preventing pressure sores
Before reading the next section, write out your own approach to the
prevention of pressure sores. For each action or guiding principle for
care, try to write out the rationale for it, together with a comment on its effectiveness or otherwise in practice.
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Now compare your practice with the principles and guidelines described in the following text. If there are differences, try to work out the
reasons for these.
In practice it can be difficult to achieve an “ideal” standard of care,
for a variety of reasons. Where we are unable to do so, it is important that
as part of our professional accountability we acknowledge it and are able
to provide a rationale for alternative practice or for omissions in care.
There are a number of research-based principles which underpin
pressure sore prevention strategies.
1) Relieving pressure. This is a primary goal both in the prevention
and the management of existing sores. This may include regular changes in
position and the use of specialist equipment designed to reduce the pressure at the patient/support surface interface, including:
• Special beds, for example, water beds, large air-filled sacks or bead
beds. These work by providing some form of floatation surface on which
the person is nursed. The principle is to spread the pressure over the largest
possible surface area, so reducing pressure over vulnerable sites.
• Special mattresses, for example, water, slashed foam or silicone
mattresses. All these use the same basic principle of increasing the area of
contact of the body with the supporting surface.
• Cushions and pads, for example, foam, air, water or gel-filled cush-
ions. These aids are designed to increase the surface area of the sacrum
and buttocks in contact with the support surface.
2) Optimizing the internal conditions for tissue health, growth and
repair, including:
• Ensuring an adequate nutritional and fluid intake. This means en-
suring that the person has access to a nutritionally balanced diet, measures
to enable the person to eat the diet and measures to counter the development of sub-clinical malnutrition in vulnerable patients/clients.
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• Preventing and treating anemia, by observing the person for signs
of anemia and consulting with medical staff about treatment where anemia
is present.
• Reviewing drug regimes for their possible effects on spontaneous
bodily movement and the healing process. For example, sedative and narcotic drugs reduce spontaneous movement, thus causing increased pressure
on certain sites of the body. Anti-inflammatory and immuno-suppressive
drugs can reduce the rate of cell replication.
3) Optimizing the external conditions for tissue health by:
• Keeping the integument healthy and intact. This involves good
personal hygiene and the protection of the skin if required with barrier
preparations.
• Promoting and maintaining continence whenever possible.
• Effectively containing any incontinence.
• Providing information and teaching to patients/clients and their
carers about: lifting techniques, regular inspection of the skin, the correct
use and maintenance of pressure-relieving aids, factors necessary for tissue
growth and repair, and self-care strategies.
• Monitoring the environment for hazards which may cause tissue
damage.
Clinical Nursing Procedure Guidelines: The prevention of pressure sores
Action
Rationale
1. Assess every patient/client
on admission or first contact, using
a recognized risk assessment tool
To identify those patients/clients at risk
from developing pressure sores
2. Reassess every patient/client
on a regular basis and or if there has been
any deterioration or change in condition
To provide appropriate data on which
to base treatment
3. Do not rub any area at risk
Rubbing causes maceration and
degeneration of subcutaneous tissues,
especially in older adults
136
Action
Rationale
4. Wash areas at risk only as part
of normal personal hygiene
or if the person is incontinent or sweating
profusely. Use mild soap or a liquid
detergent. Ensure that all detergent
or soap is rinsed off and that the area
is patted dry. Use moisturizer if the skin
is very dry. Ask the person what suits his
or her skin
To maintain skin integrity and prevent
the formation of sores. Excessive use
of soap can be harmful to the skin.
Thorough, gentle drying of the skin
promotes comfort and discourages
the growth of micro-organisms. Dry skin
cracks allow entry of micro-organisms
5. Use barrier creams only when
indicated
These act to provide a water-repellent
barrier which prevents damage
to the epidermis. They can be useful
to protect intact skin (grade 1 sores
or “at risk” areas) from moisture. They
are, however, occlusive and prevent
moisture exchange from the skin. They
may be harmful if applied to open
wounds
6. Teach the person how to shift position,
to pull or push up regularly and
to examine their vulnerable areas.
If in an armchair or wheel chair, advise
the person to try to take the weight
of their buttocks every 15 minutes
or so by leaning forward and pushing
up on the arms of the chair
Encourages participation by the person
in their own plan of care and develops
self-care knowledge and skills
7. Teach relatives and other carers how
to reduce the risk of pressure damage,
including
8.Regular changes of position
Treating pressure sores. Pressure sores are wounds and their management is the same as for any other wound (see section 5 for a detailed
discussion of the principles of wound management). Care should be
planned to prevent any further tissue damage and to promote tissue healing. This involves reviewing the cause of existing tissue distortion and the
137
conditions for wound healing. Creating the ideal systemic conditions for
healing (the relief of pressure, a good nutritional status and the prevention
or containment of continence problems) can be difficult for many patients/clients and in many settings.
Achieving healing in a pressure sore can be a very lengthy process
and in some instances may not be a realistic goal. Many people with pressure sores are in the terminal stages of illness, and this sometimes makes it
unrealistic to continue vigorous efforts to achieve healing. Preventing further tissue damage, ensuring good management of the wound and relieving
distressing symptoms such as pain and large amounts of offensive exudate,
can, however, considerably improve the person's quality of life and make
a significant contribution to his or her care and the relief of other carers.
For almost all patients/clients, teaching them watch vulnerable pressure points for themselves, and to relieve pressure at regular intervals
needs to be an important component of planned care. Achieving independence in moving and relieving pressure can often be improved by:
• Increased understanding by the person, and their caregivers, of the
risk of damage and ways of preventing further damage.
• Maximizing the person's ability to move independently, by using
aids to mobility, such as an overhead pole in bed, chair raises, the provision of “grab” rails to help the person pull him or herself up from a chair,
and standing to relieve pressure at regular intervals.
• Providing pressure-relieving aids and devices.
• Reviewing the environment for factors which limit the person's in-
dependence of movement.
• Adopting a team approach to the person's needs and involving oth-
er health care workers as necessary.
• Improving the management of any associated conditions which ex-
acerbate tissue damage, such as incontinence.
The type of treatment used is influenced by a number of factors:
• The grade of sore (see tab. 12).
• The presence of tissue necrosis.
• Infection.
• Odor.
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The grade of sore. Assessing this is useful in understanding the degree of tissue damage and in selecting the most appropriate wound covering. The criteria for an ideal wound dressing (see section 5) can be used to
guide the selection of the most appropriate wound dressing for a particular
sore and a particular patient/client. The grade of sore will usually suggest
to the nurse a number of dressings which might be appropriate. For example, for clean, superficial sores, or areas of damaged but intact skin (grade
1 and 2 sores), bio-occlusive dressings would be appropriate, as these retain moisture, reduce friction and pain, and encourage the growth of granulation tissue and epithelialization.
Necrosis and infection are often present at the same time as the pressure sore. Necrotic tissue provides an ideal environment for opportunistic
bacteria. If the wound is to be able to heal, these must be reduced to a level
that the body's defenses can cope with, and necrotic tissue must be
removed.
Pressures sores are usually infected by normal skin commensal organisms and the organisms found in the gut flora. Irrigation (with large
amounts of water or 0,9 % sodium chloride solution) is the most effective
method of reducing bacterial numbers in the sore. Systemic anti-microbial
treatments have been shown to reach wound exudate and may offer effective treatment for an infected sore.
Necrotic material includes all devitalized tissue; white, grey, soggy
tissue; and either soft or hard, black necrotic scabs. Necrotic tissue should
only be left on a wound when it provides an inert protective layer with no
collection of fluid beneath.
There are two techniques for the removal of necrotic material:
• Surgical excision. This is the most effective method of debridement, leaving a wound bed which is clean and bleeding and that can granulate freely. This method of debridement involves the complete excision of
all devitalized tissue and any fibrosed mass surrounding the sore. The procedure requires a general anesthetic, however, and therefore may be contraindicated in many patients/clients with pressure sores. Local anesthetic
is not appropriate because local anesthetic injections carry infection deeper
into the wound.
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• Topical debriding agents. These can be used as an alternative to the
more aggressive approach of surgical excision. A number of different
types of agents may be used, including chemical agents, enzyme preparations and hydroscopic agents. Each type of debriding agent has its limitations, including cost. Enzyme preparations are particularly expensive.
Odor. This is an unpleasant and distressing feature of many infected
pressure sores (and other wounds). The smell causes distress to patients/
clients, relatives and carers. Reducing odor may be an important goal for
care and may influence other decisions, such as the choice of wound covering. Treatments include:
• Charcoal in the wound dressing can be helpful as a deodorizing
filter. A number of proprietary wound dressings contain a layer of charcoal, and sheets of activated charcoal may also be available, which can be
incorporated into the final layers of a wound dressing
• Chlorophyll-containing deodorizers are more effective than floral-
perfumed deodorizers. Chlorophyll is also sometimes used as a deodorizer
in proprietary wound dressings.
• Air filters, if available, can be placed in the room, near the pa-
tient/client to freshen the air.
6.6. IMPLEMENTING PLANNED PREVENTION
AND TREATMENT OF PRESSURE SORES
The effective implementation of care for patients/clients requires the
following:
• Effectively communicating the plan of care (and the rationale for
care) to all those involved.
• A plan of care that the patient/client has been fully involved in de-
veloping. Many interventions may be unknowingly sabotaged by a patient/client who has no understanding of the rationale for that intervention,
or who has had no opportunity to voice an opinion or to exercise choice.
• Agreement and understanding of the plan of care among those in-
volved, and effective teamwork in putting it into practice. Perhaps more
140
than any other aspect of care, the prevention and treatment of pressure
sores may be governed by interventions without a rationale, by nurses' personal preferences and by a legacy of ritual and routine practice which is at
best benign and at worst actively harmful.
• Effective record sheets for recording planned care that has been
given and any deviation from the plan of care. For example, for dependent
patients/clients who require frequent changes in position, the plan of care
needs to indicate clearly the frequency of position changes and the range
of positions being used. Records are also needed to ensure that at any time
a nurse can see for how long a person has been in a particular position,
when the next change of position is due and which position should be
used next.
• Commitment to resourcing the planned care. The prevention and
treatment of pressure sores makes active demands on resources, in terms of
the organization of care and the allocation of workload, as well as on supplies of equipment and dressings. There is no value in introducing the use
of a risk assessment tool, for example, if preventative measures are not
practiced in order to reduce that risk. A commitment to resourcing care is
necessary at a variety of levels within the ward, hospital and health care
system.
6.7. EVALUATING PREVENTION AND TREATMENT
OF PRESSURE SORES
Regular and ongoing evaluation of planned care is essential. This
should include evaluation of:
• The process of establishing the optimum conditions for healing.
• The desired outcomes of care, in respect of wound healing and
management.
• Any unexpected outcomes of care, for example the development of
infection.
• The need for trouble-shooting to prevent any undesirable out-
comes, disruptions or deficits in care.
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