1. The client/caregiver can define pressure ulcer.
   1. It is an area of skin where a lack of blood flow has caused tissue destruction.
   2. It is caused by pressure, friction, or shearing (a combination of pressure and friction) force on the skin.
2. The client/caregiver has a basic understand- ing of the anatomy and physiology of the skin.
   1. The outer skin, the epidermis, is made up of layered cells. It contains the pigment that makes up our skin color.
   2. The next layer is the dermis, which contains the oil and sweat glands, hair follicles, blood vessels, and nerves.
   3. Below the dermis is the subcutaneous layer, which contains fat cells and connective tissue to act as a shock absorber and insulator for the body.
3. The client/caregiver can list factors that may increase risk of pressure ulcer.
   1. Impaired circulation and sensation
   2. Immobility
   3. Incontinence of feces or urine
   4. Malnutrition
   5. Skin pressure, friction, and shearing
   6. Edema
   7. Certain medical conditions, such as diabetes, dementia, and peripheral vascular disease
   8. Overweight or underweight
4. The client/caregiver can recognize signs of a pressure ulcer.
   1. Stage I
      1. Redness and warmth
      2. No break in skin
   2. Stage II
      1. Partial thickness
      2. Loss of skin involving epidermis and often into dermis
   3. Stage III
      1. Full-thickness skin break
      2. Involves epidermis, dermis, and subcutaneous tissue
   4. Stage IV
   5. Deep-tissue destruction
   6. Fascia, muscle, and bone involved
5. The client/caregiver can list measures to prevent pressure areas and to promote wound healing.
   1. Eliminate or decrease the force causing the skin breakdown.
      1. Use pressure-relief devices (many types of mattresses and chair cushions can be rented or purchased).
      2. Keep linens clean, dry, and free of wrinkles and crumbs.
      3. Move client with a draw sheet to prevent shearing action.
      4. Do not massage-reddened areas.
      5. Protect heels, elbows, back of head, iliac crest, sacrum, and coccyx by using foam pads.
      6. Avoid use of alcohol (because of drying properties).
      7. If incontinent, change and cleanse frequently. Encourage the use of a commode.
   2. Provide cleanliness of wound.
      1. Cleanse hands and put on gloves.
      2. Wash wound carefully and pat dry.
      3. Cover wound with dressing as ordered.
      4. Debride wound if necessary.
      5. Avoid using tape directly on the skin.
   3. Promote circulation and nutrition.
      1. Eat a high-calorie, high-protein diet and smaller, more frequent meals. Use supplemental nutritional feedings.
      2. Take vitamin and mineral supplements including multivitamins, vitamin C, and zinc.
      3. Exercise to increase circulation and bring nutrients to the wound.
      4. Avoid alcohol and cold temperatures, which constrict blood vessels.
      5. Provide a controlled moist environment.
      6. Lubricate dry skin.
      7. Use ointments to protect skin from excessive moisture and incontinence.
      8. Use skin-care products as recom- mended (i.e., hydrocolloid dressings and Tegaderm).
      9. Deep wounds require packing to absorb drainage.
   4. Activity
      1. Change position every 2 to 3 hours while in bed or chair.
      2. Increase activity as tolerated.
      3. Teach safe transfer methods.
      4. Teach active and passive range of motion.
   5. Stress the importance of frequent checks of pressure points (sacrum, hips, heels, elbows, ears, and thoracic spine).
6. The client/caregiver can list possible complications.
   1. Infection
   2. Septicemia

Resources

Durable Medical Equipment Companies for Pressure-Relief Devices
Nurse Wound Therapist Consult
Occupational or Physical Therapist Consult
Dietician Consult
Home Health Aid

References

Ackley, B. J., & Ladwig, G. B. (2006). Nursing diagnosis handbook: A guide to planning care. Philadelphia: Mosby Inc.
Cohen, B. J., & Wood, D. L. (2000). Memmler’s the Human Body in Health and Disease (9th ed.). Philadelphia: Lippincott Williams & Wilkins.
Nutrition made incredibly easy. (2003). Springhouse: Lippincott, Williams & Wilkins.
Portable RN: The all-in-one nursing reference. (2002). Springhouse: Lippincott, Williams & Wilkins.
Taylor, C., Lillis, D., & LeMone, P. (2005). Fundamentals of nursing. Philadelphia: Lippincott Williams & Wilkins. Timby, B. K., & Smith, N. C. (2003). Introductory medical-surgical nursing (8th ed.). Philadelphia: J. B. Lippincott
Williams & Wilkins.

Credits

Client Teaching Guides for Home Health Care, 2nd ed.
© 2008 Jones and Bartlett Publishers, Inc.
www.jbpub.com