Question

Based on the Flow chart for prevention and management of Pressure injuries by AWMA, what are the nursing considerations in prevention and management of pressure injury? Use the table to write strategies. Write a minimum of 3 strategies for each care realm. Care realm Nursing considerations/ strategies 36.1) Mobility 36.2) Nutrition 36.3) Reducing friction and shear 36.4) Relieving pressure 36.5) Wound management 36.6) Skin Moisture management

Answer 1

Answer :

Localized areas of tissues necrosis which develop when soft tissue is compressed between a bony prominence and an external surface For a prolonged period of time .

Most pressure ulcers occur over bony prominences ,where combined with friction and shearing forces result in skin breakdown .

Several factors other than pressure contribute to ulcers including moisture , friction , shear , immobility ,sensory loss and some underlying medical conditions .

Pressure injuries can be difficult to treatment and can lead to serious complications .

Classification :

Stage one : darkly pigmented skin may not have visible blanching ,its color may differ from the surrounding area.

Stage 2 : partial thickness loss of dermis presenting as a slallow open ulcer with a red pink wound her , without slough .

Stage 3 : full thickness tissue loss , subcutaneous fat may be visible but bone ,tendon or muscles are not exposed .

Stage 4 : full thickness tissue loss with exposed bone ,tendon or muscle .

Prevention of pressure injuries and nursing interventions :

• It is important to be aware of the risk of pressure sores .
• To prevent skin damage We need to relieve the pressure , reduce the time that pressure is applied and improve skin quality .

Mobility :

Passive range of motion ,physical therapist consultation to plan appropriate measures For patient .

• We need to mobilise the patient who are bed ridden .
• Regular Position changing is very important .
• Nurse should change the position every 2nd hourly ,even during the night and to avoid lying directly ob their hipbones .
• Avoid direct pressure on bony prominences
• Pillows may be used as soft buffers between the skin and bed or chair .

Nutrition :

• Provide high protein diet to the people who are having pressure injury For early wound healing .
• Make sure the person eats  healthy and nutritious diet .

Reducing friction and shear : Use her trapeze or pull sheet For lifting and moving patient up in bed .apply transparent film or hydrocolloid dressing over friction areas .keep the head of the her leaa than 30degrees as often as possible

• Provide air or water bed to the bedridden cases to avod friction and shear .
• Provide soft cloth or mat under the patient .
• Be aware of using good hygiene practices .
• Maintain activity level ,where appropriate .
• Use moisturising products to kerp skin supple and prevent dryness .
• Never massage bony areas because the skin is too delicate .
• Keep the skin at right moisture level ,as damage is more likely to occur if skin is either too dry or too moist .
• Check the skin at least daily For redness or signs of discoloration .

Relieving moisture :

• Avoid wetness under the wound area
• Clean the urinals and faeces as early as possible .
• Dont place wet clothes under the wound area because it increases the infection and lead to poor wound healing .
• Always Use dry , soft clothes or pillows to avoid further damage of skin.

Wound management :

• Manage incontinence ,keeping area clean and dry .
• Use moisture barrier cream PRN .
• Cleanse with normal saline ,apply small amount of hydrogel and cover with non adherent dressing ,change every day .
• Off load area of pressure ulcer with pressure relieving /distribution surface and turning and repositioning schedule
• Sharp debridement / enzymatic debridement
• Use foam or calcium alginate dressing For moderate to copious drainage management .
• Castor oil /balsam /peru /trypsin spray is preffered treatment .

Skin moisture management :

Use moisturizing lotions

Dont massage the area

Apply moisture barrier creams