Pressure ulcers are a common occurrence in bed bound patients, even though they can be avoided. Let’s go over the nursing responsibilities surrounding pressure ulcers, how to prevent them, stage them, and treat them.
What are Pressure Ulcers?
Pressure ulcers are wounds typically seen in bed bound patients on bony prominences that are constantly in contact with the bed or another surface. One of the most common places to have a pressure ulcer is over the sacrum. Pressure ulcers have also been noted on patients who require supplemental oxygen around the ears where the tubing rests. These ulcers are caused by not properly offloading and/or turning the patient and not protecting these bony prominences.
What are Bony Prominences?
Bony prominences are any area where the bone is only covered by a thin layer of skin rather than muscle and/or fat. Because there is only skin between the bone and the bed or the medical device, a wound is more likely to develop if special precautions are not taken.
These areas include:
- Sarum
- Elbows
- Heels
- Toes
- Shoulder blades
- Back of the head
- Ears
- Hips
- Knees
Prevention
Because pressure ulcers are caused by pressure over bony prominences, it is most reasonable to assume you first need to offload the pressure. There are various ways to offload pressure, the simplest being to turn your patient every one to two hours. The next is to order an offloading device, such as inflatable boots to offload pressure from the heels and toes and/or a specialty mattress.
Additionally, making sure there is not any medical tubing touching the patient of laying under them will help prevent pressure ulcers. Provide the patient with a clean, dry area and always change out wet or soiled linens as quickly as possible. Always try your best to avoid friction.
Staging Pressure Ulcers
Because pressure ulcers are typically caused by improper turning of patients, it is important to document exactly when the pressure ulcer is seen and in what stage. If you ever see a patient with a pressure ulcer that has not been documented, be sure to chart accordingly. Do this by taking pictures of the wound and letting the doctor know the next time he/she rounds. You may even need to put in a new order for a wound consult depending on the stage of the wound.
So how do you stage a pressure ulcer?
Stage 1 – Nonblanchable Redness
The first sign of a pressure ulcer is nonblanchable redness. Meaning that you can visualize redness that does not ‘blanch’, or go away, with slight pressure to the skin. If this occurs, you have a stage 1 pressure ulcer.
Stage 2 – Partial Thickness
A Stage 2 pressure ulcer involves tissue loss in the first two layers of skin, the dermis and the epidermis. This wound will appear red or pink in color and will look more superficial than a Stage 3 or Stage 4 wound. There will be no bruising or sloughing of the skin.
Stage 3 – Full Thickness Skin
Stage 3 pressure ulcers will be past the first two layers of skin and into the subcutaneous tissue. The ulcer will be deep, but no muscle or bone will be exposed.
Stage 4 – Full Thickness Tissue
A Stage 4 pressure ulcer is the deepest wound. It will appear like a Stage 3 pressure ulcer, but with the addition of visualized muscle or bone. With a full thickness wound, there may be deep tunneling or undermining of the wound with eschar or sloughing. With a Stage 4 pressure ulcer, there will be a deep infection of the wound.
Unstageable
A wound is considered unstageable when there is too much slough or eschar covering the wound so that the deepest part of the wound is not able to be visualized. A wound can go from unstageable to a certain stage, but a wound can never be downgraded once it is able to be staged. For example, if a wound is covered in so much eschar that it is unstageable but then it is debrided and now the edges can be approximated, then it can be restaged to a Stage 3 or 4 pressure ulcer. Then if the wound starts to heal, and you can no longer see the bone as you could before, then you would define the wound as a Stage 4 healing pressure ulcer. You cannot give the wound a lower stage as it heals.
Treatment of Pressure Ulcers
In order to help heal pressure ulcers, we must provide patients with adequate fluids and a proper diet including lots of protein. If antibiotics are ordered, make sure to administer them at the scheduled times. Make sure that the area is kept clean, and any dressing change orders are followed exactly. Continue to turn the patient and provide them with offloading devices.
Wound Care
For wound care and documentation, see Nursing Fundamentals: A Guide to Wounds.
And that’s it! Check out the rest of the Nursing Fundamentals Series listed below!
- Diabetes
- Pain
- Infection Control
- Identifying Sepsis and Understanding its Care and Treatment
- A Guide to End-of-Life Care
- And the entire Nursing Fundamentals Series!