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Pressure Ulcer Prevention & Management Cheat Sheet by

Best Practices: Treating Pressure Ulcers
medical     ulcer     pressure     healthcare     sores     treatments

Assessment

The Rn or LPn/LVn should perform a full-body skin assessment within 8 hours of admission and during every shift . The Braden scale (Braden & Maklebust, 2005) is used to assess a patient’s risk for skin breakdown . Reasse­ssment using this tool is determined by setting or patient condition . The level of risk is identified according to the score obtained (any score below 18 indicates a risk).

Inspect the patient’s skin

Particular attention should be paid to vulnerable areas, especially over bony promin­ences and all (15) locations listed below must be inspected:
occiput
ears
scapulae
elbows
ribs – both anterior and posterior chest wall
spinous processes
iliac crests
sacrum
ischial tubero­sities
trochanters
genitals
knees
malleoli
heels
feet
other locations (so the entire body is inspected)

Stage 1 Treatment

Goal
Inte­rve­ntion
Prod­uct
Protect the skin and remove the cause
Change position in bed or chair every two hours.
Assess need for support surface.
Maintain head of bed at 30 degrees or less, unless contraindicated.
Use draw sheet for repositioning.
Do not massage reddened areas.
Elevate heels off bed with pillow or protective boots/splints.
Avoid positi­oning on affected area.
Transparent film
Thin wound dressing
 

Pressure Bed Sores

Stage 2 Treatment

Trea­tment
Inte­rve­ntion
Prod­uct
Protect the skin and manage exudates; closure and regrowth of ski
Manage exudat­es/­moi­stu­re: Apply wound dressing; change every 3–5 days and prn.
None­-to­-light exudat­es: Ointment to affected area, need MD order; a thin wound dressing
Mode­rat­e-t­o-heavy exudat­es: Adhesive wound dressing or a nonadh­esive wound dressing secured in place
Ointment
Thin wound dressing
Adhesive wound dressing
Nonadhesive wound dressing

Stage 3 & 4 Treatment

Goal
Trea­tment
Prod­uct
Protect and keep wound clean; manage exudates; and reduce wound size
Manage exudat­es/­moi­stu­re: Apply a wound dressing to create a moist wound enviro­nment, which assists in autolytic debrid­ement of wounds covered with necrotic tissues
None­-to­-light exudat­es: Apply a thin wound dressing or gel
Mode­rat­e-t­o-heavy exudat­es: Adhesive or nonadh­esive wound dressing secured in place; selection of dress- ing influenced by size and location of the pressure ulcer; a rope or sheet wound dressing may be needed in specific situations or to pack the wound; change every 1–3 days and prn, cover.
Gel
Thin dressing
Adhesive wound dressing
Non-adhesive wound dressing
Rope or sheet wound dressing

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