diseases

Pressure ulcers, also known as decubitus ulcers or bedsores, are localized injuries to the skin and/or underlying tissue that usually occur
over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction. The most common sites are
the sacrum, coccyx, heels or the hips, but other sites such as the elbows, knees, ankles or the back of the cranium can be affected.
A pressure ulcer is a wound unlike any other, in that its cause is not surgery or trauma but death of the
skin and underlying tissues from ischemia due to unrelieved pressure. There are many factors that
contribute to the development of a pressure ulcer and whether or not it will heal, but the biggest factor in
all of these is pressure.
Common terms for a pressure ulcer include bedsore, decubitus ulcer, pressure sore, and pressure ulcer.
The terms bedsore and decubitus ulcer originated from the notion that to develop ulcers a person
needed to be bedridden, which we now know is not the case. Ulcers can develop when a patient
constantly maintains any position; consequently the term pressure ulcer most accurately describes an
ulcer from pressure.
Over the years, the definition of a pressure ulcer has been refined. The most recent definition from the
National Pressure Ulcer Advisory Panel states that a pressure ulcer is ―a localized injury to the skin
and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in
combination with shear and/or friction‖ (EPUAP/NPUAP, 2009).
The compression of soft tissue interferes with the tissue‘s blood supply, leading to vascular insufficiency,
tissue anoxia, and cell death. Pressure ulcers can develop within 24 hours of the initial pressure but take
as long as a week to present themselves. The first tissues to die are nearest the bone, and as the
pressure and anoxia continue, the remaining layers of tissue begin to die. The skin is the last to die. The
damage resembles an iceberg, with a smaller amount of damage visible at the surface and a large
amount of damage below the surface.
Pressure ulcers usually occur over bony prominences such as the sacrum, ischium, heel, and trochanter,
where there is less tissue to compress. Other factors—such as friction and shearing, poor nutrition, and
incontinence—also contribute to the tissue breakdown.

THE IMPACT OF PRESSURE ULCERS
The most recent figures available indicate that 2.5 million patients are treated annually for pressure
ulcers in acute care facilities in the United States (IHI, 2007). The impact of pressure ulcers is staggering.
 First and foremost, these wounds are very painful, thus causing patients a great deal of suffering.
 The anatomical location of the ulcer may result in a loss of dignity.
 Quality of life is affected, as the patient must alter activities to help heal the wound and may face long-term hospitalization.
 A nonhealing ulcer is at high risk for infection, which can be life threatening.
 Ulcer treatments may require surgical procedures such as debridement, colostomies, and amputations, which the patient would
otherwise not have to face.
 An ulcer that heals forms scar tissue, which lacks the strength of the original tissue and is more easily ulcerated again and again.
 Most importantly, the presence of a pressure ulcer increases the risk of death. Nearly 60,000 hospital patients in the United States are
estimated to die each year from complications due to hospital-acquired pressure ulcers (IHI, 2007). Likewise, actor Christopher
Reeve, who had been a quadriplegic for the last nine years of his life, died from complications due to an infected pressure ulcer.
Healthcare costs increase dramatically due to pressure ulcers. An estimated $11 billion are spent each
year to treat pressure ulcers. The inpatient length of stay is 3–5 times longer for those with a pressure
ulcer. Patients with either a primary or secondary diagnosis of pressure ulcer are discharged to long-term
care at three times the rate of other diagnoses (WOCN, 2010).
Pressure ulcers also increase healthcare practitioners‘ workloads, as now additional time and care must
be provided to manage and treat patients‘ pressure ulcers—more dressing changes, more medications,
and more documentation.
Litigation may be brought against a hospital and its staff for neglect, malpractice, and elder abuse if a
patient develops a pressure ulcer while in the hospital. Awards can be in the millions of dollars. And the
bad publicity that follows will damage the hospital‘s reputation, bottom line, and trust patients have that
they can be cared for safely.
Pressure ulcers are reportable to state and federal agencies. The information is placed in published
reports accessible by the public, which then allows the public to compare facility outcomes. Regardless
of the care setting (acute, SNF, home health, and inpatient rehabilitation facilities), all providers must
account for the number of pressure ulcers that were present on admission and on subsequent
reassessments, whether they have closed or worsened (Lyder & Ayello, 2012).
Governmental agencies may levy fines against the hospital for pressure ulcers. The Center for Medicare
and Medicaid (CMS) no longer pays a hospital for the additional care needed for a patient who develops
a hospital-acquired pressure ulcer (HAPU), but the hospital must provide the care nonetheless.
In the long-term care setting, the Joint Commission has again made the prevention of healthcare-
associated pressure ulcers a 2014 National Patient Safety Goal (Joint Commission, 2013).
Thus, the assessment, prevention, and treatment of pressure ulcers are of major importance to
healthcare professionals and to the facilities at which they practice. Many facilities have developed
pressure ulcer prevention programs to put these ideas into practice and prevent negative outcomes.

RISK ASSESSMENT
The purpose of assessing the risk for developing pressure ulcers is to implement early detection and
prevention measures. This is of utmost importance, as assessment without intervention is meaningless.
Risk Factors for Pressure Ulcers
Certain groups of patients have a higher risk for developing pressure ulcers. These include:
 Patients who are older adults (those over age 65 are at high risk and those over age 75 are at even greater risk)
 Patients in critical care
 Patients with a fractured hip (an increased risk for heel pressure ulcers)
 Patients with spinal cord injuries (spasticity, the extent of the paralysis, a younger age at onset, difficulty with practicing good skin
care, and a delay in seeking treatment or implementing preventive measures increase the risk of skin breakdown)
 Individuals with diabetes, secondary to complications from peripheral neuropathy
 Individuals who are wheelchair- or bed-bound
 Patients who are immobile or for whom moving requires significant or taxing effort (i.e., morbidly obese)
 Patients who struggle with incontinence
 Patients with neuromuscular and progressive neurological disesases (i.e., multiple sclerosis, ALS, Myasthenia gravis, stroke)
AGING SKIN
Obvious changes in both skin structure and function occur with aging. These changes contribute to the occurrence of skin and wound problems.
 A flattening of the epidermal-dermal junction decreases the overall strength of the skin, which increases the risk for skin tears and
blistering.
 A decrease in the melanocytes and Langerhans cells increases the risk for allergic reactions and sensitivity to sunlight.
 A decrease in blood flow decreases skin temperature.
 A decrease in oil and sweat production contributes to dryness and flaking.
 A decrease in subcutaneous tissue, especially fat, decreases the body‘s natural insulation and padding.
 A decline in the reproduction of the outermost layer of the epidermis may lead to the skin‘s inability to absorb topical medications.
These changes in skin structure and function, together with the risks that occur with a change in overall health and functional ability, put an aged
patient at very high risk for the formation of a pressure ulcer.
There are other risk factors that may increase the chance of developing a pressure ulcer. More than 100
risk factors have been reported (WOCN, 2010). Some of these include:
 General medical conditions, such as diabetes, stroke, multiple sclerosis, cognitive impairment, cardiopulmonary disease, cancer,
hemodynamic instability, peripheral vascular disease, malnutrition, and dehydration
 Smoking
 History of a previous pressure ulcer (since scar tissue is weaker than the skin it replaced and will breakdown easier than intact skin)
 Increased facility length-of-stay
 Undergoing surgery longer than 3 hours
 Significant weight loss
 Prolonged time on a stretcher, such as in the emergency room
 Medications, such as sedatives and analgesics
 Refusal of care, such as when a patient refuses to be turned or moved despite education
 Edema
 Obesity
 Patient not being turned
 An ICU stay, due to the high acuity of illness, presence of multiple comorbid conditions, and:
o Mechanical ventilation
o Vasopressors and hemodynamic instability
o Multiple surgeries
o Increased length of stay
o Inability to report discomfort
Risk Assessment Schedules
The skin is the largest organ in the body, and the clinician needs to assess it regularly. The assessment
of pressure ulcer risk should be performed when a patient is admitted to any healthcare setting. It should
be repeated on a regular schedule per facility policy and/or when there is a significant change in the
patient‘s condition, such as surgery or a decline in health status (EPUAP/NPUAP, 2009).
A schedule for reassessing risk should be based on the acuity of the patient, judgment of the clinician,
and knowledge of when pressure ulcers are most likely to occur in a clinical setting. Every patient must
be assessed and reassessed, not just the ones who seem most likely to develop ulcers. In fact, a recent
study (Bye et al., 2012) showed that in one hospital system, almost 25% of patients who had developed
hospital-associated pressure ulcers had been identified as low risk. Recommendations based on the
healthcare setting are included in the box below. A particular facility or setting may have different
regulations.
ASSESSMENT SCHEDULES BY HEALTHCARE SETTING
Acute Care: In acute care, pressure ulcers can develop within the first 2 weeks of hospitalization. Elderly patients can develop pressure ulcers
within the first week of hospitalization. The initial assessment is conducted upon admission and repeated at least every 24–48 hours, whenever
the patient‘s condition changes, or per facility policy. Most ICUs reassess each shift, while a medical-surgical unit may reassess daily.
Home Health: In home healthcare settings, most pressure ulcers develop within the first 4 weeks. The initial assessment is conducted upon
admission and repeated at resumption of care, recertification, transfer or discharge, or whenever the patient‘s condition changes. Some agencies
reassess with each nursing visit.
Long-term Care: In long-term care settings, most pressure ulcers develop within the first 4 weeks. In skilled facilities, the initial assessment is
conducted upon admission and repeated weekly thereafter. In nursing homes with long-term patients, the assessment is conducted upon
admission, repeated weekly for the first month, and repeated monthly thereafter, or whenever the patient‘s condition changes.
Source: WOCN, 2010.
What Needs to Be Assessed
Prevention of pressure ulcers must begin with frequent and routine assessment of the patient‘s skin and
of the risk factors that, if left unmanaged, will contribute to the development of an ulcer. A head-to-toe
inspection of the skin must be done on admission and at least daily (or per facility regulation). The
assessment should focus on high-risk areas such as bony prominences. The specific areas to assess
are shown in the table and diagram below.
ASSESSING A PATIENT’S SKIN
If the patient’s position is: Then focus on these areas:
Lateral Ear, shoulder, trochanter, knee, ankle
Supine Occiput, shoulder blades, elbows, sacrum, heels, toes
Semi-recumbent Occiput, shoulder blades, elbows, sacrum, ischial tuberosities
Seated Shoulder blades, spinal protrusions, elbows, sacrum, ischial tuberosities, heels

Bony prominences are high-risk areas for pressure ulcers. (Source: © Invacare Corporation. Used
with permission.)
Blanchable erythema is a reddened area that temporarily turns white or pale when pressure is applied
with a fingertip. This is an early indication of pressure. Nonblanchable erythema is redness that persists
when fingertip pressure is applied. It means that tissue damage has already occurred.
It can be difficult to identify skin problems in patients with dark skin. Redness may not be easy to see.
The clinician needs to compare the at-risk area (such as the coccyx or hip) with skin next to it and look
for color differences or changes in temperature or pain.
ASSESSMENT AND MEDICAL DEVICES
Medical devices such as shoes, heel and elbow protectors, splints, oxygen tubing, face masks,
endotracheal tube holders, compression stockings, and others must be removed and the skin inspected
daily. If the device cannot be removed—such as a nasogastric (NG) tube, urinary catheter, tracheostomy
holder, or cast—then the skin around the device must be carefully inspected: the nares for an NG tube,
the throat for a tracheostomy, the thigh for a urinary catheter, etc.
All such devices have caused pressure ulcers. Ulcers caused by medical devices are reportable to state
and federal agencies, just as are those caused by pressure on bony prominences.
ASSESSMENT AND MOBILITY
Immobility is the most significant risk factor for pressure ulcer development. More frequent monitoring to
prevent pressure ulcers is conducted for patients who have some degree of immobility, including those
who are:
 Nonambulatory
 Confined to bed, chairs, wheelchairs, recliners, or couches for long periods of time
 Paralyzed and/or have contractures
 Wearing orthopedic devices that limit function and range of motion
 Dependent on assistance to ambulate or reposition themselves
ASSESSMENT FOR FRICTION AND SHEARING
Friction is the mechanical force of two surfaces moving across each other; damage includes blisters or
abrasions. Patients who cannot lift themselves during repositioning and transferring are at high risk for
friction injuries. Shearing is the mechanical force that is parallel to the skin and damages deep tissues
like muscle. Tissues attached to the bone are pulled in one direction while surface tissues remain in
place. Shearing most commonly occurs when the head of the bed is elevated and the patient slides
downward. Friction is most common when patients are turned or pulled up in bed.
ASSESSMENT FOR INCONTINENCE
Moisture from incontinence can contribute to pressure ulcer development by macerating the skin and
increasing friction injuries. Fecal incontinence is an even greater risk for pressure ulcer development
than urinary incontinence because the stool contains bacteria and enzymes that are caustic to the skin.
When both urinary and fecal incontinence occur, the fecal enzymes convert the urea in the urine to
ammonia, which raises the skin‘s pH. When the skin pH is elevated (alkaline), the skin is more
susceptible to damage. Pressure ulcers are four times more likely to develop in patients who are
incontinent than in those who are continent (WOCN, 2010).
ASSESSMENT FOR NUTRITIONAL STATUS
Although individual nutrients and their specific role in preventing pressure ulcers have not been
determined, malnutrition is associated with overall morbidity and mortality. A nutritional assessment
should be conducted upon admission or when there is a change in the patient‘s condition that would
increase the risk of malnutrition, such as the patient‘s refusal to eat or eating less than usual, prolonged
NPO status, or development of a wound(s) or other conditions that increase metabolic demand.
CASE
Mr. Frank is a 90-year-old man who has been admitted to the hospital with pneumonia. He fell at home three months ago and was also
hospitalized at that time. His equally elderly wife denies that she is having any difficulty caring for him and says that he eats well and takes all his
medications.
The admitting nurse finds Mr. Frank to be very thin and that he weighs 10 pounds less than when he was hospitalized after his fall. His
incontinence brief is saturated with urine, and his perineal skin is raw. He does not move himself in the bed. The nurse recognizes that Mr. Frank
is at high risk for developing a pressure ulcer due to his poor nutrition, his immobility, and his incontinence.
The nurse discusses with the physician the patient‘s need for a dietician referral, a pressure reduction mattress, and a barrier product to protect
his skin. She alerts the discharge planner that Mr. Frank may require home health or possibly nursing home placement after the pneumonia is
cleared, as his wife, despite her intentions, is having difficulty caring for her husband.
Determining Risk Levels
Several risk assessment tools or scales are available to help predict the risk of a pressure ulcer, based
primarily on those assessments mentioned above. These tools consist of several categories, with scores
that when added together determine the total risk score. The Braden and Norton Scales for predicting
pressure ulcer risk are the most widely used in a variety of healthcare settings. The clinician uses these
tools to help determine risk so that interventions can be started promptly. These tools are only used for
assessing adults. For those who work with children, the Braden Q Scale has subcategories that relate to
assessing children (see ―Resources‖ at the end of this course).
BRADEN SCALE
The Braden Scale consists of six categories:
 Sensory perception: Can the patient respond to pressure-related discomfort?
 Moisture: What is the patient‘s degree of exposure to incontinence, sweat, and drainage?
 Activity: What is the patient‘s degree of physical activity?
 Mobility: Is the patient able to change and control body position?
 Nutrition: How much does the patient eat?
 Friction/shear: How much sliding/dragging does the patient undergo?
There are four subcategories in each of the first five categories and three subcategories in the last
category. The scores in each of the subcategories are added together to calculate a total score, which
ranges from 6–23. The higher the patient‘s score, the lower his or her risk. (For more information, see
―Resources‖ at the end of this course.)
 Less Than Mild Risk: ≥19
 Mild Risk: 15–18
 Moderate Risk: 13–14
 High Risk: 10–12
 Very High Risk: ≤9
It is recommended that if other risk factors are present—such as age, fever, poor protein intake, or
diastolic blood pressure less than 60 mm Hg—the risk level should be advanced to the next level. Each
deficit that is found when using the tool should be individually addressed, even if the total score is above
18. The best care occurs when the scale is used in conjunction with nursing judgment. Some patients will
have high scores and still have risk factors that must be addressed, whereas others with low scores may
be reasonably expected to recover so rapidly that those factors need not be addressed (Braden, 2012).
NORTON SCALE
The very first pressure ulcer risk evaluation scale, called the Norton Scale, was created in 1962 and is
still in use today in some facilities. It consists of five categories:
 Physical condition
 Mental condition
 Activity
 Mobility
 Incontinence
Each category is rated from 1 to 4, with a possible total score ranging from 5 to 20.
 Low risk: ≥18
 Medium Risk: 14–17
 High Risk: 10–13
 Very High Risk: <10
It is important that when the clinician uses a scale, the scale must not be altered in any way, meaning
there cannot be shortcuts or changes to the definitions. Any changes would alter the accuracy and
usefulness of the scale in predicting the risk of developing pressure ulcers.
Risk assessment is more than an act of determining a numerical score; it requires identification of those
risk factors that contribute to that score and minimizing the deficits by the appropriateness of the intensity
and effectiveness of prevention interventions (Kelechi et al., 2013).

PRESSURE ULCER PREVENTION
As the saying goes, ―An ounce of prevention is worth a pound of cure.‖ It is more cost efficient to prevent
a pressure ulcer than to cure one. Interventions that will help the clinician prevent pressure ulcers do so
from both an outside and inside approach. From the outside, the clinician can minimize pressure through
regular repositioning, using a support surface, and managing incontinence to prevent skin damage from
moisture. The inside approach includes the management of nutrition and hydration to support the body in
preventing damage and healing any damage that has occurred.
Regular Repositioning
As previously stated, immobility is the most significant risk for the development of pressure ulcers. High
pressures over bony prominences for a short time and low pressures over bony prominences for a long
time are equally damaging (EPUAP/NPUAP, 2009). In order to decrease the risk, it is important to
reduce the time and amount of pressure the patient is exposed to.
All patients must have their positions changed on a regular schedule. How often this is done is
determined by each patient‘s activity/mobility level, general medical condition, overall treatment plan,
skin condition, and support surface.
To further assess a patient‘s immobility, a referral to the physical therapist is most helpful in devising
interventions and providing education to increase mobility. The therapist can educate the patient, family,
and staff on safe ways to help keep the patient as mobile as possible.
BED-BOUND PATIENTS
For bed-bound patients, the standard ―turn every two hours‖ may be more than adequate for some but
not at all adequate for others. A patient needs to be repositioned more often on a standard mattress than
on a pressure-redistributing mattress. If the medical condition is so severe that repositioning the patient
regularly is not possible, then a support surface designed to decrease pressure must be used. For
instance, a low air-loss mattress should be considered in this case.
Which support surface is available for use may depend on facility contracts and sometimes a patient‘s
insurance. A facility‘s equipment department will indicate which options are available to the patient.
When we think of turning the patient, we often think that the patient must be completely over on a side.
This can be difficult for the clinician/caregiver to do, is uncomfortable for the patient, can result in cardio-
pulmonary compromise, and actually increases pressure on the side of the body.
Frequent small position changes, rather than completely turning the patient, is faster, easier, and safer
for all. Any change in position is beneficial. The patient need only be tilted to the side, no more than 30
degrees, with pillows or wedges to help support and reduce the pressure over bony prominences. A
small pillow behind the shoulder or the hip alters position without having to move the entire body.
Bending the knee alters the pressure on the sacrum and hip. A small pillow behind the heel will elevate
the heel off the surface and prevent pressure.

A small turn using a bolster can be as effective as a full turn. (Source: Author.)
When a patient is moved, it must be done in a way so as to prevent friction and shearing, as these forces
will cause skin injury as readily as pressure.
 Always use a lift sheet or lift equipment to reposition the patient.
 The patient must be lifted, not dragged, while repositioning, which also means more than one person may be needed to move the
patient. Pulling or dragging the patient will cause skin damage due to friction.
 Maintain the head of the bed at or below 30 degrees (or the lowest degree of elevation allowed based on the medical condition) to
prevent the body from sliding down and causing a shear-related injury (WOCN, 2010).
 Lower the head of the bed one hour after meals or intermittent tube feedings. If this is not possible, the sacral region will need to be
checked even more frequently for possible injury.
When moving a patient, always use good body mechanics and request help when needed. Have the
patient assist in moving by using overhead trapeze bars. Even if the patient can only hold onto the bar,
some of the weight will be reduced, making it easier and safer to move the patient. After the patient has
been repositioned, be sure that he or she is not lying on a medical device, such as tubes or drains, and
make sure the linens are smoothed.
CHAIR-BOUND PATIENTS
A chair-bound patient must be repositioned as well. When a patient is seated, the weight of the body
causes the greatest amount of pressure to occur over the ischial tuberosities. Since this area of the body
is relatively small, the amount of pressure will be high; without pressure relief, a pressure ulcer will occur
quickly. If the patient cannot sit upright but slouches in the chair, then the sacral area is at risk as well.
Recommendations for the chair-bound patient include:
 Stand the patient and reseat them in the chair.
 Elevate the legs or place the feet on a stool if the feet do not reach the floor. This will prevent sliding forward out of the chair.
 Elevate the feet and recline the chair by 30 degrees to reduce pressure.
 If the patient can change his/her own position, encourage pressure relief every 15 minutes. This includes chair pushups, leaning
forward, leaning side to side, or tilting backwards. Leaning forward is the most effective and might be easier than chair push-ups.
 Acutely ill patients at risk for pressure ulcers should not sit for longer than two hours at a time and not return to sitting for at least an
hour.
 Patients with existing pressure ulcers on the ischial areas should limit time sitting up in the chair to three times a day for 60 minutes or
less, and they must use a cushion (gel or air cushions are best) that redistributes pressure (WOCN, 2010).
Physical and occupational therapists are of great importance in assessing and managing the immobile
patient‘s activities and instructing staff, patients, and families in proper techniques to avoid injury and
prevent ulcers. This may include assessing the seating and positioning needs of individuals who are
wheelchair-bound. Proper wheelchair positioning with an individualized seating system can promote
good posture, enhance breathing and digestion, prevent complications such as pressure sores and skin
irritation, slow further loss of mobility, minimize pain, and maximize functioning. Components of a
wheelchair seating system may include specialized supportive cushions, backrests, headrests, and trunk,
arm, and leg supports.
CASE
Patricia is a 61-year-old female with multiple sclerosis, leaving her bedridden and unable to move her legs. Despite being on a pressure reduction
surface, she has developed a stage III pressure ulcer at her sacrum because of refusing to be turned due to the severe pain she experiences
each time her right leg is moved. This has made it very difficult for the staff to provide wound care and keep Patricia clean. Furthermore, pain
medication has not been effective for Patricia‘s very intense but brief pain.
The nurse asks the physical therapist for recommendations to make moving Patricia less painful for her and less stressful for the staff. After
assessing Patricia, the therapist directs using localized heat treatments to her right leg, gentle manipulation, and exercise. After several
treatments with the therapist, Patricia is able to tolerate turning toward her right side and staying in position for the time needed to care for her
wound and clean her. The therapist also instructs the staff about less painful ways to move Patricia‘s leg when necessary. As a result, Patricia no
longer screams out in pain when repositioned.
Using Support Surfaces
There is no mattress, cushion, or bed that will eliminate pressure and relieve the clinician or caregiver
from having to turn the patient. Patients must still be turned, no matter what surface is used. Support
surfaces on beds and chairs are used, however, to more evenly distribute body-weight pressure and to
help reduce pressure to any one area of the body.
CHOOSING A SURFACE
Determining the appropriate support surface is based first on the patient‘s condition and the healthcare
setting. Overall, if the patient is able to be turned and has at least two intact turning surfaces, meaning
the skin is intact on two sides of the body, then a mattress overlay or an alternating pressure pad can be
used over a regular mattress. If the patient has skin breakdown on more than one side of the body, then
a mattress replacement should be used.
Next, cost and product availability must be considered in choosing a surface. The healthcare setting will
also determine the product used. For instance, in the home setting the weight of the bed, the structure of
the home, the width of the doors, and the availability of uninterrupted electrical power will have a major
impact on the support surface available for use.
In general, a standard hospital mattress should not be used with at-risk patients. Be sure to contact the
medical equipment department to determine what is available for pressure reduction (WOCN, 2010).
Rings, foam cutouts, or donuts under the patient should not be used, as these concentrate pressure on
surrounding tissue, causing swelling and decreasing circulation. The fact that they can be found in
medical supply stores does not mean they are safe to use.
TYPES OF SUPPORT SURFACES
 Replacement mattresses: Mattresses with pressure-reducing features placed on an existing bed frame in place of a standard
mattress
 Overlays: A support surface placed on top of a standard mattress; made of foam, water, gel, air, or a combination
 Foam: A thick slab of foam with a textured surface placed on top of a standard mattress to reduce pressure by surrounding the
body; should be at least 3–4 inches thick to be effective at reducing pressure (2 inches is for comfort only)
 Water: A vinyl mattress or overlay with sections filled with water to distribute pressure more evenly and create a flotation effect
 Gel: Made of a thick fluid that conforms to the contours of the body
 Air: A vinyl mattress or overlay inflated with a blower to reduce pressure; powered or dynamic mattresses have a pump that
inflates the mattress sections in an alternating cycle
 Low–air loss: A mattress or overlay with controlled air-flow sections
 Air-fluidized: Uses a high rate of blown air to fluidize fine particulate material (such as silicone beads) to ―float‖ the patient on the
surface
Rotational support systems (beds that rotate side to side automatically) are used to support pulmonary
and circulatory function and are not sufficient for repositioning a patient to decrease the risk of a
pressure ulcer. This is because the patient‘s skin never leaves the bed surface and therefore pressure is
not relieved off the skin.
For patients who spend most of their time sitting, proper support cushions are required. Pillows or pieces
of foam might be comfortable, but they do not redistribute body weight to help decrease pressure.
In some healthcare settings, it is the occupational therapist who determines the correct support cushion;
in others, it is the physical therapist. Nurses should not hesitate to refer the patient to either of these
experts if needed.
ENSURING EFFECTIVENESS OF THE SUPPORT SURFACE
The support surface chosen must be approved for the patient‘s body size and weight. Most conventional
support surfaces are for patients who weigh 300 pounds or less. If the patient weighs more than this,
then a bariatric mattress and frame must be obtained.
Even in patients who weigh less than the weight limit, where their weight is concentrated may make a
difference in the mattress needed. The mattress may not be able to support the patient when the body
weight is not evenly distributed. For instance, a paralyzed patient or an amputee may weigh under the
limit, but most of the weight will be concentrated in the trunk.
If it looks as though the patient is lying or sitting in a ―well,‖ the surface may not be able to support the
patient‘s weight. Provided the support surface is the correct one, check for any disconnected hoses or
machine settings that may have been inadvertently changed. Contact the appropriate hospital
department, supplier, or the manufacturer to have the support surface checked as needed.
With the use of any support surface, the number of linens and other items used under the patient must
be kept at a minimum or the pressure-reducing ability of the surface will be altered significantly. Staff,
patients, and family members must be instructed to use no more than two items between the patient and
the surface, e.g., one pull sheet and one incontinence pad or product.
Regardless of the surface used, the patient‘s heels must be floated off the bed using either a pillow or a
heel-lift device. The recommended position for the pillow is lengthwise under the calf with the heel
suspended off the pillow. The patient must still be turned at regular intervals to promote pulmonary,
renal, and vascular function along with protecting skin integrity. Padded devices such as synthetic
sheepskin, bunny boots, or rigid splints protect the heels from friction and shearing but do not relieve
pressure. Devices such as an IV bag, rolled towel, or sheet do not redistribute pressure and can actually
increase pressure (WOCN, 2010).

Heels are properly floated. (Source: Author.)
Managing Incontinence
Skin moisture from incontinence is a risk factor for pressure ulcer development. Water saturates the skin,
which increases the risk that friction and shearing will result in erosion of the skin. The ammonia in urine
raises the skin‘s pH, which promotes growth of pathogenic bacteria, disrupts the protective acid mantle,
and activates fecal enzymes. Fecal enzymes damage the skin, allowing the gastrointestinal bacteria to
cause infections. These result in a condition called incontinence-associated dermatitis(IAD). In and of
itself, IAD is not a pressure ulcer. But if unrelieved pressure is added to IAD, the odds are five times
higher that a pressure ulcer will develop. Proper cleansing and protection of the skin are the basis of
prevention of IAD (Gray et al., 2012).
Cleanse the skin gently with a pH-balanced cleanser at each incidence of soiling. Perineal skin cleansers
are more effective for prevention and treatment of IAD than traditional soap and water. This is because
bar soap, which is alkaline and very drying, disrupts the skin‘s protective abilities. Vigorous cleaning, as
well as the use of rough washcloths, can also lead to skin erosion. Soft, disposable cloths are easier on
the skin. Avoid cleaning products with fragrance or alcohol, as these are irritants. Some facilities use no-
rinse foams, which are another good option.
An incontinence skin barrier product should be used to protect the skin after cleansing. Products such as
creams, ointments, pastes, or those that form a film on the skin are all useful. Protective products with
dimethicone, petroleum, or zinc oxide are recommended for patients with fecal incontinence or both
urinary and fecal incontinence to protect against IAD. Several manufacturers offer products that both
clean and protect, saving time for the caregiver and increasing the likelihood that perineal care will be
performed.
Select underpads or incontinence briefs that are absorbent to wick moisture away from the skin instead
of those that trap the moisture against the skin. However, all briefs increase moisture at the perineal
region because they are occlusive and do not ―breathe.‖ This creates warmth near the skin that, when
combined with moisture, ammonia, and enzymes, increases skin breakdown. There is an increased risk
with the use of briefs because they may not be changed as often as they should be due to the difficulty in
seeing when a patient has voided. Briefs are not recommended for fecal incontinence because they can
trap stool against the skin.
Many hospitals have moved away from using briefs except when a patient is ambulating or going off the
ward. Instead, they use underpads that are especially designed to keep the skin dry and breathable and
do not allow heat or moisture to be trapped against the skin.
A toileting program can also decrease incontinence and thus IAD. For those patients with significant fecal
output, a pouching system or fecal containment device may be necessary to protect the skin from the
effluent. In situations where the severity of urinary incontinence has contributed to or may contaminate
an existing pressure ulcer, placing a urinary catheter may be indicated (WOCN, 2010).
TYPES OF INCONTINENCE
Type Description Causes/Associated Factors
Sour ces: Pal mer , 1996; Rei chenbach, 1998a, 1998b.
Urge
incontinence
Involuntary loss of urine with an abrupt strong
need to void; occurs with the involuntary
contractions of the detrusor muscle or
uncontrolled urethral relaxation
Associated neurological disorders include stroke, paraplegia, multiple
sclerosis, Parkinsonism, or dementia.
Stress
incontinence
Involuntary leakage of small amounts of urine
with a rise in intra-abdominal pressure that
occurs during coughing, sneezing, laughing, and
physical activity
Often seen in women; causes include estrogen deficiency, weakness in
pelvic floor musculature, urethral sphincter weakness, childbirth, and
obesity.
Functional
incontinence
Individual with a functional urinary tract is unable
or unwilling to get to the toilet to urinate
Often occurs in older adults; contributing factors include use of physical
restraints, musculoskeletal dysfunction, unavailability of a urinal, visual
impairment, impaired mobility, cognitive deficits, unfamiliarity of
environment, and psychosocial difficulties.
Overflow
incontinence
Involuntary loss of urine secondary to over
distension of the bladder; results in the leakage
of small amounts of urine due to an outflow
obstruction or a hypotonic bladder
Common causes include medications, neurological conditions such as
diabetic neuropathy or spinal cord injury, prostate enlargement, detrusor
weakness, or urethra stricture.
Mixed
incontinence
Combination of other types of urinary
incontinence, typically urge and stress
incontinence
Common in older adults
OCCUPATIONAL THERAPY AND INCONTINENCE
Occupational therapists (OTs) are specialists in assessing and identifying the underlying impairments associated with urinary incontinence.
Common interventions that can be implemented by OTs include:
 Pelvic Floor Muscle Training (PFMT): a program of repeated pelvic floor muscle contractions
 Scheduled toileting (i.e., timed voiding): monitoring and then matching of the individual‘s typical toileting schedule
 Habit retraining: identifying the individual‘s natural voiding pattern and developing an individualized toileting schedule
 Prompted voiding: establishing a routine in which a caregiver suggests voiding and provides assistance as needed
Research indicates that the use of a toileting routine in combination with medication and education results in decreasing urinary incontinence.
CASE
Ruth is an elderly woman living in a residential treatment facility. She has a stage IV pressure ulcer on her sacrum that the nurse is treating per
the physician‘s orders. The nurse has been educating the facility‘s caregivers about the importance of keeping Ruth‘s perineal skin clean, dry, and
protected. Upon several instances of checking Ruth, however, the nurse finds both Ruth and her sacral dressing to be wet with urine. A caregiver
also reports to the nurse that the dressing requires changing several times a day due to urine saturation.
The nurse knows that exposure to urine can delay or prevent wound healing. Remembering that frequent dressing changes can also delay
healing, the nurse advises the physician of Ruth‘s incontinence and wound status. The physician writes an order for an indwelling urinary catheter.
The nurse inserts the catheter per protocol and instructs the caregivers in its maintenance. When assessing Ruth after a couple of days, the nurse
notes that the catheter has kept Ruth and the sacral dressing dry, resulting in improvement of her wound.
Managing Nutrition
Malnutrition is associated with overall morbidity and mortality. Thus, assessing the patient‘s nutritional
status must be part of the total assessment for pressure ulcers. A nutrition assessment should be
performed upon admission and whenever there is a change in the patient‘s condition that puts him or her
at risk for malnutrition.
NUTRITION ASSESSMENT PARAMETERS
 Current weight and usual weight
 History of unintentional weight loss or gain (>5% change in 30 days or >10% change in 180 days)
 Body mass index (BMI)
 Food intake
 Dental health
 Ability to chew, swallow, and feed oneself
 Medical and/or surgical history that influences intake or absorption of nutrients
 Drug/food interactions
 Psychosocial factors that can affect food intake
 Ability to obtain and pay for food
 Facilities for cooking and eating
 Food preferences
 Cultural and lifestyle influences on food selection
 Over 65 years of age
The patient should be monitored for signs of dehydration, such as decreased skin turgor and/or urine
output or elevated serum sodium. Serum protein tests, such as for albumin and pre-albumin, may be
affected by inflammation, renal function, and hydration and so may not correspond with overall nutritional
status. Thus, laboratory tests should be considered as only one part of the nutritional assessment.
While there is evidence that adequate nutritional support for stage III and IV pressure ulcers is a strong
predictor of pressure ulcer healing and that support with high protein can significantly reduce the risk of
pressure ulcers, there is no evidence to support that specific supplements promote the healing of ulcers.
Studies that show support are few and more research needs to be done (WOCN, 2010).
Any patient with nutritional and pressure ulcer risks, suspected or identified nutritional deficiencies, or a
need for nutritional supplementation to prevent undernutrition should be referred to a registered dietician.
Any patient with a pressure ulcer should be referred to the dietician as well (WOCN, 2010).

STAGING PRESSURE ULCERS
Pressure ulcers are staged to classify the degree of tissue damage that is present. The staging system
was originally created in 1975 as a means to describe the amount of anatomical tissue loss in a pressure
ulcer. The use of stages in pressure ulcer assessment is a way to classify the amount and type of tissue
destroyed based on anatomic depth. Having and using a common classification system allows all
clinicians a way of communicating accurately about what is wrong. It is only used to describe pressure
ulcers, not other wounds.
The most current staging system from the National Pressure Ulcer Advisory Panel (EPUAP/NPUAP,
2009) is described below.
Stage I
A stage I pressure ulcer is defined as intact skin with nonblanchable redness of a localized area, usually
over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from
the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent
tissue.
A blanchable redness means that when the red area is compressed by the finger, the area turns white or
pale and the redness returns when the pressure is released. Nonblanchable redness means the area
under the finger remains red as it is compressed. Nonblanchable redness indicates that tissue damage
has already occurred. (See figure.)

Stage I pressure ulcer. (Sources: [illustration] © NPUAP, used with permission; [photo] © Wound,
Ostomy and Continence Nurses Society (WOCN), used with permission.)
Stage II
A stage II pressure ulcer refers to partial thickness loss of dermis presenting as a shallow open ulcer with
a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled
blister or as a shiny or dry shallow ulcer without slough or bruising.
(Slough is a soft, moist, avascular tissue. It may be white, yellow, tan, or green; loose or firmly adherent;
and described as resembling ―chicken fat.‖ Bruising indicates deeper tissue injury.)
This stage should not be used to describe skin tears, tape burns, perineal dermatitis (incontinent-
associated dermatitis), maceration, or excoriation. ―Partial thickness‖ means that the damage is confined
to the epidermis and/or dermis but does not penetrate below the dermis. (See figure.)

Stage II pressure ulcer. (Sources: [illustration] © NPUAP, used with permission; [photo] © WOCN, used
with permission.)
Stage III
A stage III pressure ulcer includes full-thickness tissue loss, meaning the damage extends completely
through the dermis to the subcutaneous layer. Subcutaneous fat may be visible, but bone, tendon, or
muscle is not exposed. Slough and/or eschar may be present but does not obscure the depth of tissue
loss. The ulcer may include undermining (tissue destruction to underlying, intact skin along the wound
edges) and tunneling (a path of tissue destruction that occurs in any direction from the surface or edge of
the wound).
(Eschar is black or brown necrotic tissue. It can be loose or firmly adherent; hard, soft, or boggy; and
look like a scab, although there is no healing occurring beneath it.)
The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear,
occiput, and malleolus do not have subcutaneous tissue, and stage III ulcers here will be shallow. In
contrast, areas of significant fat deposits can develop extremely deep stage III pressure ulcers. (See
figure.)

Stage III pressure ulcer. (Sources: [illustration] © NPUAP, used with permission; [photo] © WOCN,
used with permission.)
Stage IV
A stage IV pressure ulcer involves full-thickness tissue loss with exposed bone, tendon, or muscle.
Slough or eschar may be present on some parts of the wound bed. It often includes undermining and
tunneling.
The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear,
occiput, and malleolus do not have subcutaneous tissue, and stage IV ulcers here will be shallow.
Stage IV ulcers can extend into muscle and/or supporting structures, such as fascia, tendons, or joint
capsules, making osteomyelitis possible. Exposed bone or tendon is visible or directly palpable. (See
figure.)

Stage IV pressure ulcer. (Sources: [illustration] © NPUAP, used with permission; [photo] © Association
for the Advancement of Wound Care (AAWC), used with permission.)
Suspected Deep Tissue Injury
The NPUAP has also described two additional categories of pressure ulcer: suspected deep tissue injury
and unstageable (EPUAP/NPUAP, 2009).
Deep tissue injury may be indicated by a purple or maroon localized area of discolored intact skin or a
blood-filled blister due to damage to the underlying soft tissue from pressure and/or shear. The area may
be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent
tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Its evolution may
include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin
eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. (See
figure.)

Suspected deep tissue injury. (Sources: [illustration] © NPUAP, used with permission; [photos] ©
AAWC, used with permission.)
Unstageable
A pressure ulcer is considered unstageable in the case of full thickness tissue loss in which the actual
depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown tissue) and/or
eschar (tan, brown, or black tissue) in the wound bed. Until enough slough and/or eschar are removed to
expose the base of the wound, the true depth cannot be determined; however it will end up to be a stage
III or IV, as slough and/or eschar do not form in stage I or II ulcers.
Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heels serves as the body‘s
natural or biological cover and should not be removed. (See figure.)
This ulcer will continue to be described as unstageable.

Unstageable pressure ulcer. (Source: [illustration] © NPUAP, used with permission; [photo] © AAWC,
used with permission.)
Reverse Staging
The term reverse staging came about in the 1980s as a way of describing improvement in an ulcer.
However, this term does not accurately describe what is physiologically occurring in the ulcer. Because
staging is used only to describe the amount and type of tissue destroyed based on anatomic depth, it
cannot be used to describe healing.
As a pressure ulcer heals, it does decrease in depth, but the body does not replace the lost bone,
muscle, subcutaneous fat, or dermis. Instead, the full-thickness ulcer is filled with granulation, or scar
tissue, and then covered with new epithelium. Even a partial-thickness stage II ulcer does not return to
the nonblanchable redness of a stage I ulcer. A stage IV pressure ulcer that has closed should be
classified as a closed stage IV pressure ulcer and not as something like a stage O pressure ulcer (which
does not exist).
The progress of healing a pressure ulcer can only be documented using wound characteristics (decrease
in length, width, depth, odor, drainage, pain, etc.) or using a validated pressure ulcer healing tool. If a
pressure ulcer reopens in the same anatomical site, the ulcer resumes the previous staging diagnosis—
once a stage IV, always a stage IV (EPUAP/NPUAP, 2009).

PRESSURE ULCER TREATMENT
Treating a pressure ulcer involves all of the activities used in preventing a pressure ulcer: the proper
pressure-reducing surface, repositioning the patient correctly and frequently, maintaining intact skin, and
improving nutrition. While these interventions are started, the treatment of the wound itself also begins.
There are basic wound-care principles that can be used in deciding which treatments will be the best for
the wound and for the patient. Frequent reassessment of the wound and its response to the treatment is
required, as well as eliminating or reducing the factors that inhibit wound healing.
Pressure Reduction
Of all the interventions that must be done to heal the ulcer, pressure reduction measures are the most
important. Simply put, the wound will not heal unless the pressure is removed. Trying to heal a pressure
ulcer without reducing the pressure is like trying to heal a stab wound with the knife still in it. You might
get some improvement, but the wound will never heal because the primary cause has not been removed.
Repositioning and turning must be done regularly and frequently. Friction and shear must be prevented
or a small ulcer will quickly turn into a large one with undermining and tunneling. (A ―classic‖ pressure
ulcer is round; one that is misshapen with undermining and tunneling has had friction and shear placed
on it.) The right support surface for the bed or the chair must be obtained and used. Management of
incontinence will keep skin from getting worse. While outside impediments to healing are being
managed, the inside impediments can be attended to through proper nutrition and by reducing other
factors that affect healing.
Universal Principles of Wound Management
The object of treatment is to reproduce (to the best of one‘s ability) the normal environment of the
exposed tissue of the wound. The normal environment of all tissue and cells, with the exception of the
epidermis, is warm, dark, moist, and protected. In order to heal any wound, including pressure ulcers,
some basic principles need to be followed. These are:
 Remove necrotic tissue
 Treat infection
 Fill dead space
 Maintain a moist wound environment
 Protect the wound from infection, trauma, and cold
Some of these principles will require medical intervention; others, good clinical care. By following these
principles, caregivers will provide the wound with the environment it needs to heal.
DEBRIDEMENT: REMOVING NECROTIC TISSUE
Removing necrotic tissue is the critical first step when healing the ulcer is the goal. By removing dead
tissue, bacteria and the risk for infection are decreased as well as drainage and odor. Removing these
materials may also contribute to the release of available growth factors in the wound, thus allowing the
cells to multiply and heal the wound.
The removal of necrotic tissue is called debridement, of which there are several types. The most
appropriate type of debridement will depend on the patient‘s overall condition and goals of care. Factors
to consider include the status of the ulcer; the type, quantity, and location of the necrotic tissue; the
presence or absence of infection; pain tolerance; the care setting; and professional accessibility
(EPUAP/NPUAP, 2009).
Removing the necrotic tissue will often reveal the true size of the ulcer and the damage done—the
―iceberg‖ effect. The patient and family should be educated that the ulcer will look worse after
debridement and that the ulcer cannot heal without debridement.
Surgical
Performed by a surgeon at the bedside or in the operating room, surgical debridement is the quickest
way to remove extensive necrotic tissue, undermining, and tunneling. The benefits of surgical
debridement in the presence of advancing cellulitis, crepitus, fluctuance, and/or sepsis secondary to
ulcer-related infection usually outweigh the risks. However, relative contraindications include
anticoagulant therapy, bleeding disorders, and immune incompetence. If the necrotic ulcer is on a limb, a
thorough vascular assessment is conducted prior to debridement to rule out arterial insufficiency. The
NPUAP recommends against debridement of stable, hard, dry eschar in ischemic limbs
(EPUAP/NPUAP, 2009).
Conservative, sharp debridement—as opposed to surgical debridement—may be performed by specially
trained, competent, qualified, and licensed healthcare professionals consistent with local, legal, and
regulatory statutes. Sharp debridement removes only loose, easily identifiable necrotic tissue.
Autolytic
This method allows the body to break down necrotic tissue by using its own enzymes and defense
mechanisms. Autolytic debridement is accomplished with the use of occlusive dressings such as
hydrocolloids and films. These dressings help maintain a moist wound environment, reduce pain, and
provide a barrier to infections. The dressing is left on for a few days, allowing the accumulation of fluids
and enzymes at the site. The dressing is removed, the wound cleansed, and new dressing applied. This
method takes time but is effective.
Chemical
This method involves the use of enzyme debriding agents. These agents break down necrotic tissue
without affecting viable tissue. The enzyme product is applied daily to the necrotic tissue and then
covered by a dressing. Enzymes are by prescription only, and currently only one is available on the
market.
Biosurgical
This method uses sterilized bottlefly maggots, which debride the wound by dissolving dead and infected
tissue with their digestive enzymes (in other words, the maggots eat the dead tissue). The maggots also
disinfect the wound by killing bacteria. This in turn stimulates the growth of healthy tissue. (For futher
information, see ―Resources‖ at the end of this course.)
Mechanical
Mechanical debridement utilizes physical forces to remove necrotic tissue.
In the past, the most common type of mechanical debridement was the use of wet-to-dry dressings and
whirlpools, but wet-to-dry dressings are no longer recommended. In this method, wet gauze is applied to
the wound and necrotic tissue is allowed to dry and then forcibly removed without re-wetting. The gauze
will have stuck to the necrotic tissue, thus removing it when the gauze is removed. However, this method
is nonselective in that healing tissue will also be removed, thus re-traumatizing the wound bed and
causing significant pain. The use of whirlpools has also fallen out of favor due to the difficulty in assuring
the equipment is free of pathogens before its use on the next patient.
High-pressure wound irrigation is now used with commercially available devices, such as pulsatile lavage
units. A lower-pressure method to debride tissue is to use a 35-ml syringe with a 19-g needle held a few
inches from the wound. Care must be taken to minimize splashing and exposure to wound drainage.
Infection control precautions should be followed.
TREATING INFECTION
Infection is not common in stage I or II ulcers; therefore, assessing for infection is focused on stage III
and IV ulcers. Pressure ulcers that are infected may exhibit subtle signs of infection—such as new or
increased pain, delayed healing, poor or friable granulation tissue, discoloration of wound bed tissue, a
change in odor, increased serous drainage, induration, or pocketing—before the classic signs of infection
occur. There should be a high suspicion for the likelihood of infection in ulcers with necrotic tissue, those
that have been present for a long time, those large in size, or those repeatedly contaminated, such as
those near the anus.
It is important to look for local infection in ulcers that have no signs of healing after two weeks of
treatment. An acute infection may be present if there is redness extending from the ulcer edge, warmth,
purulent drainage and odor, increase in size of the ulcer, and increase in pain. Systemic symptoms such
as fever and malaise may develop. The elderly may develop confusion and anorexia. There must also be
a high suspicion for the likelihood of infection in patients who have diabetes, malnutrition, hypoxia,
autoimmune disease, or immunosuppression.
The gold standard method of determining wound infection is by a culture of tissue obtained by biopsy.
However, an acceptable alternative to a tissue culture is a swab culture obtained by the Levine technique
(EPUAP/NPUAP, 2009).
LEVINE TECHNIQUE FOR WOUND CULTURE
 Cleanse wound with sterile normal saline; blot dry with sterile gauze.
 Culture the healthiest-looking tissue in the wound bed.
 Do not culture drainage, pus, necrotic tissue, or fibrous tissue.
 Rotate the end of a sterile alginate-tipped applicator over a 1 cm by 1 cm area for 5 seconds.
 Apply sufficient pressure with the swab to cause tissue fluid to be expressed.
 Send the specimen to the lab.
If the culture indicates infection, a two-week course of topical antibiotics is used to treat the infection.
Consider systemic antibiotics if bacteremia, sepsis, advancing cellulitis, or osteomyelitis has occurred.
Systemic antibiotics cannot reach necrotic tissue, so topical antibiotics are recommended in addition to
systemic (EPUAP/NPUAP, 2009).
Silver- and honey-impregnated dressings are an option for ulcers infected with multiple organisms
because these dressings offer broad antimicrobial coverage. Be sure the patient is not allergic to honey
or to bees before using a honey dressing.
Topical antiseptics such as povidone iodine, Dakin‘s solution, or acetic acid that are properly diluted may
be used for a limited time to control the bacterial burden, clean the ulcer, and reduce surrounding
inflammation. Once the wound is clean, these products should be discontinued, as they can be
damaging to healthy tissue. These products can also be used to control bacteria, drainage, and odor in
wounds that are not expected to heal, such as in a terminally ill patient (EPUAP/NPAUP, 2009).
Cleansing the wound will also reduce the risk of infection. The ulcer and the surrounding skin must be
cleansed at each dressing change. The cleansing method should provide enough pressure to remove
debris yet not enough to cause trauma to the wound bed. Techniques for cleansing may include
irrigation, gently swabbing the wound, or showering.
Pressure ulcers that are healing may be cleansed with water; tap water, distilled water, cooled boiled
water, or saline are all options. Avoid using cleansing products that are designed for use on intact skin,
and avoid cleaners that are designed to remove fecal material; both of these can be toxic to a wound.
When the wound has a lot of drainage or debris, a commercial wound cleanser may be used. Those that
contain surfactants can help remove wound contaminants (WOCN, 2010).
FILLING DEAD SPACE AND MAINTAINING A MOIST ENVIRONMENT
Wound dressings are a central component of pressure ulcer care. The selection of the dressing for the
ulcer is very important and based on many parameters, such as:
 Presence of infection or necrosis
 Size, depth, and presence of undermining or tunneling
 Location
 Drainage
 Condition of the surrounding skin
 Goals for healing
 Individual or caregiver needs, such as pain reduction or odor control
 Cost/reimbursement of the dressing
 Availability
 Ease of use
(WOCN, 2010)
Maintaining a moist wound is a primary factor in dressing selection. If the ulcer is draining a large
amount, then a dressing that will absorb but not dry out the wound is needed. If the ulcer has minimal
drainage, then a dressing that replaces moisture and/or doesn‘t allow the ulcer to dry out is needed.
The ―dead‖ space inside the wound needs to be filled so that the dressing is in contact with the wound
bed, including any tunneling or undermining. A wound should not be stuffed with the dressing material;
stuffing the wound puts pressure on the inside of the wound and will prevent exudate from draining out.
Dressings are changed based on the amount of drainage: a heavily draining wound will need to be
changed often, while a minimally draining wound can be changed less than daily. There are many
dressings available today to help maintain the correct environment to allow healing. It is important to
follow manufacturer recommendations for the use of the product (Hess, 2013).
EXAMPLES OF DRESSING TYPES FOR PRESSURE ULCERS
Hydrocolloid (e.g., Duoderm): A type of dressing containing gel-forming agents applied to a foam or a film, which form an absorbent, self-
adhesive, waterproof occlusive wafer. These dressings are used in stage II ulcers in body areas where they will not roll or melt. They are also
used for autolytic debridement. Expect the formation and/or collection of drainage under the wafer. This does not indicate infection but is a
property of the product. Do not use on infected or heavily draining wounds or wounds in which the dressing needs to be changed more than three
times per week. Remove carefully.
Transparent film: Can be used to protect body areas at risk for friction injury. Can be used for autolytic debridement. May be used as a
secondary dressing to hold in other dressings. Remove carefully.
Hydrogel: Water- or glycerin-based gel, impregnated gauzes, and sheet dressings used to add moisture to a wound. Generally, these dressings
are used on shallow, minimally draining ulcers. They are covered with a secondary dressing.
Alginate: These are used in moderately and heavily draining ulcers. Cover with a secondary dressing.
Foams: Used in draining stage II and shallow stage III ulcers. They absorb drainage and protect the wound.
Gauze: A cotton or synthetic weave that is absorptive and permeable to water, water vapor, and oxygen. Gauze may be impregnated with
petrolatum, antiseptics, or other agents. Gauze should not be used in clean ulcers, as they are labor-intensive to use, cause pain when removed
if dry, and will dry out a wound. However, if no other dressing is available, the use of gauze that is kept continually moist is preferable to dry
gauze. Moist gauze can be used to loosely fill a cavity wound and one with undermining and tunneling.
Negative Pressure Wound Therapy (NPWT): These mechanical systems include a vacuum pump, drainage tube, and dressing set. The use of
NPWT has been associated with increased rates of healing in stage III and IV pressure ulcers. Necrotic tissue must be debrided prior to using
NPWT. Follow manufacturer guidelines for use.
ANTIMICROBIAL DRESSINGS
Silver-impregnated dressings: An antimicrobial dressing used in ulcers that are infected or at high risk for infection. The silver is incorporated
into foam, alginate, and other dressings. The silver is activated when it comes in contact with wound fluid. Consider discontinuing use when
infection is controlled and/or drainage reduces significantly. Can turn tissues a dark color. Do not use in patients allergic to silver.
Honey-impregnated dressings: FDA-approved manuka honey is used for antimicrobial effects and can be effective on antibiotic-resistant
bacteria while promoting healing. Used in stage II, III, and IV ulcers. Assists in debridement. Do not use in patients allergic to bees or honey.
Cadexomer iodine: An antimicrobial dressing containing iodine that absorbs drainage and matter from the wound surface, and as it becomes
moist, the iodine is released. Used in moderately to highly draining wounds. Do not use in patients with iodine sensitivity or thyroid disease.
Difficult to use in large-cavity wounds.
Impregnated gauze dressings: A gauze dressing impregnated with polyhexethylene biguanide that provides a barrier to bacteria and inhibits
the growth of bacteria in the dressing, thus protecting the wound and potential spread of bacteria from the wound. Used in place of plain gauze.
Many of the advanced dressings do not need to be changed daily, which reduces pain, time, and expense. Follow manufacturer directions.
PROTECTING THE WOUND FROM INFECTION, TRAUMA, AND COLD
Protecting the wound from infection, trauma, and cold can be done through the proper cleansing and
dressing of the wound. As a wound heals and the drainage decreases, choose a dressing that does not
have to be changed often. Every time a dressing is removed and the wound cleansed, the temperature of
the wound bed drops to room temperature. The body then must expend energy to bring the wound bed
back to body temperature so that cell repair and growth can continue. This can take several hours. Less-
frequent dressing changes aid the wound in healing by giving it time to do so. Protecting the wound from
trauma includes the proper support surface, protection from incontinence, and the use of dressings that
do not need to be changed frequently.
Monitoring Healing
With each dressing change, the ulcer is observed for anything that may indicate the need for a change in
treatment—e.g., improvement or deterioration, more or less drainage, signs of infection, or other
complications. Any signs of deterioration should be addressed immediately. The type of dressing may
need to be changed based on this assessment. For example, an antimicrobial dressing may be needed,
or a more absorptive dressing used, or a change made in frequency of wound care.
Stage I and II pressure ulcers should show evidence of healing within 1–2 weeks, and stage III and IV
ulcers should show evidence of healing within 2–4 weeks. This means that if after two weeks of
treatment there has been no healing or signs of improvement, then all the risk factors need to be
reevaluated and the plan of care revised to reflect new interventions.
HEALING ASSESSMENT TOOLS
There are several tools for assessing pressure ulcer healing. The Bates-Jensen Wound Assessment
Tool (BWAT) is comprised of fifteen items, of which thirteen are scored from 1–5. The total scores and
dates of assessment can be plotted on a graph, which provides an index of improvement or deterioration
of the wound. (See ―Resources‖ at the end of this course.)
The PUSH tool (Pressure Ulcer Scale for Healing) was developed by NPUAP. An ulcer is categorized
using numerical scores of 0–5 according to surface area (length times width), drainage amount, and
tissue type. A comparison of the total scores measured over time provides an indication of improvement
or deterioration in the ulcer.
Many computer systems also have programs to monitor ulcer progress. Of course, the clinician will also
use clinical judgment to assess signs of healing, such as a decrease in the amount of drainage, pain,
and wound size and an improvement in wound bed tissue. The clinician can also use photography,
comparing baseline and serial photographs to monitor healing over time. Follow facility policy on the use
of photography.
FACTORS THAT AFFECT WOUND HEALING
In the case of a nonhealing pressure ulcer, when the choice of wound care is appropriate and pressure is
being relieved, then the patient needs to be reassessed for other reasons why the ulcer is not improving.
One systematic approach to determining what other factors might be affecting wound healing utilizes the
acronym DIDN’T HEAL. Using this acronym and correcting those factors that can be corrected will aid in
healing the ulcer. If factors cannot be corrected, healing the ulcer may not be possible.
DIDN’T HEAL
Cause Description Additional Factors
Sour ce: Sti l l man, 2010.
Diabetes Lack of diabetic control affects wound healing by causing diminished
cardiac output, poor peripheral perfusion, and a decrease in the ability of
WBCs to function
 Fasting blood sugar >80–120 mg/dl
 A1C >6.5%
Infection Increases the destruction of collagen needed for repair
 Overwhelms body defenses
DIDN’T HEAL
Cause Description Additional Factors
Drugs Can impair collagen synthesis
 Steroids
 Chemotherapy (high risk for
infection/malnutrition)
 Immunosuppressants (interfere with healing)
Nutrition Deficiencies impair normal wound healing
 Diet lacks adequate calories, protein, vitamins
 Obese patients not necessarily well-nourished
Tissue
necrosis
Impairs wound healing due to lack of oxygen
 Cell death as a result of all the factors
Hypoxia Inadequate tissue oxygenation
 O2 saturation <92%
 Anemia
 Poor circulation
 Comorbid conditions such as heart failure,
pneumonia, CVA
 Pain
Excessive
tension
Tension on wound edges leads to local tissue ischemia and necrosis
 When the patient is moved, wound is pulled
Another
wound
Competition for all the factors needed for wound healing impairs wound
healing at all sites
 Increased nutritional needs
Low
temperature
Further deceases oxygen to the wound
 Poor circulation
 Use of cold cleansing solutions
 Frequent dressing changes that cause wound
temperature to drop to room temperature
DETERMINING THE NEED FOR SURGICAL INTERVENTION
A patient with a stage III or IV ulcer that has not responded to conservative medical treatment may be
evaluated for operative repair. Prior to surgery the patient should be in an optimal state both mentally
and physically, and factors that impair healing should be minimized. The patient‘s ability to tolerate the
surgery and participate in the postoperative rehabilitation must be assessed prior to any surgery. Some
patients may not be surgical candidates due to malnutrition, immobility, poor compliance with treatment,
or chronic diseases.
Operative procedures may include skin grafts or flaps (surgical reconstruction). Which option is available
may be limited due to previous surgeries, a shortage of available tissue to use, and impaired blood
supply. Immediately after surgery, the operated region must be totally offloaded. Once the surgical
incision has healed, the patient will be allowed to gradually apply pressure to the area.
Rates of surgical complications and recurrence rates are high. Complication rates have been reported as
high as 49%. Osteomyelitis is the major cause of breakdown after surgery (WOCN, 2010).
Documentation
The very basics of documentation are to document what was observed, what was done (including
education provided), and how the patient responded. Documentation of pressure ulcer management
includes an assessment of the ulcer on admission and at least weekly thereafter (or per agency
regulations) for any signs of skin and/or wound deterioration, along with documentation of risk
assessment and patient/family education provided. The following parameters are also documented:
 Onset, course, and duration of the ulcer
 Description of the ulcer
 Pain (location, intensity, quality, onset, duration, alleviating/aggravating factors)
 Patient/caregiver‘s ability and willingness to adhere to the prevention and treatment program
 Prevention interventions that were initiated (referrals to dietary, physical therapy, occupational therapy, support surface management,
skin care management, etc.)
 Discussions conducted with, and observations made by physicians
The description of the ulcer includes the physical characteristics of the ulcer itself and of at least 4 cm of
the surrounding tissue (Hess, 2013). The following factors should be included in the documentation of
any wound.
ANATOMIC LOCATION
Describe where on the body the wound is, including the nearest bony prominence or anatomic landmark.
Descriptors such as anterior-posterior, medial-lateral, or proximal-distal can clarify location.
STAGE
Use the staging definitions described earlier in this course.
DRAINAGE OR EXUDATE
 Amount: Light or scant, moderate, heavy or large, copious
 Color: Serous (clear, watery plasma); sanguineous (bloody); serosanguineous (plasma and red blood); purulent (thick, odorous,
possibly yellow, green, or brown)
ODOR
Odor defines the presence or absence of high bacteria counts in the ulcer and should be assessed only
after cleaning the wound. Almost all drainage has an odor. A strong or foul odor from the wound bed
suggests infection. A mild odor may be due to the particular wound care products in use.
DESCRIPTION OF THE PERIWOUND SKIN
 Color: There may be redness, pallor, blanchable erythema, nonblanchable erythema, or purple discoloration.
 Temperature: Warmth may indicate further tissue breakdown or underlying infection.
 Induration: Abnormal firmness with a definite margin may indicate infection.
 Maceration: Softening of tissues may be due to soaking from wound drainage or contact with urine and/or stool.
 Denuded: Superficial skin loss may be due to drainage or trauma (such as from tape).Excoriation refers to linear scratch-like marks,
not to skin loss from trauma or incontinence.
TYPE OF TISSUE EXPOSED (APPEARANCE OF WOUND BED)
 Red: May indicate clean, healthy granulation tissue. Granulation is a pink or red moist tissue composed of new blood vessels and
connective tissue that fills an open wound when it starts to heal. It usually has an irregular, granular surface, like velvet. Not all red
tissue is granulation.
 Yellow: May indicate the presence of drainage or slough. Slough is a soft, moist, avascular (lacking blood supply) tissue that may be
yellow, white, tan, or green. It may be loosely or firmly attached. Sometimes resembles chicken fat.
 Black: May indicate the presence of eschar or necrotic tissue, which slows healing and allows bacteria to grow. It may be brown or
tan and can be hard or soft or loosely or firmly attached. It can resemble a scab, but there is no healing occurring under it.
WOUND MEASUREMENTS
Always use a single-use, metric tape measure. Never measure using ―coins‖ (dime-sized, quarter-sized,
etc.). Measurements should be done at least weekly.
 Length: Linear distances from wound edge to wound edge. To measure consistently, look at the wound as if it were a clock face: the
top of the wound (12 o‘clock) is toward the patient‘s head. The bottom of the wound (6 o‘clock) is toward the patient‘s feet. Length is
the longest distance measured from 12 to 6 o‘clock.
 Width: Width is longest distance measured from side to side, or from 9 to 3 o‘clock.
 Depth: The distance from the visible surface to the deepest point in the wound base. Measure depth using a cotton-tip applicator,
holding it perpendicular to the wound edge, placing the finger at the point on the swab that corresponds to the wound edge. While
still holding this measurement, remove the swab and measure it on the tape measure.
 Undermining: Use a cotton-tip applicator to probe to the deepest part of the undermining. Mark the depth between the end of the
applicator and the wound edge with the finger and measure it against the tape measure. Describe the location of the undermining
using the clock face (e.g., ―undermining extends from 12 o‘clock to 5 o‘clock and is deepest at 3 o‘clock at 3 cm‖).
 Tunneling or sinus tract: Measure the tract as for undermining and describe its location using the clock face.
Wound care documentation includes a variety of information that reflects the wound status while it heals.
Providing an accurate description of the skin and wound characteristics is critical following each dressing
change. These findings of the ulcer‘s current status will help the clinician in revising the plan of care and
treatment strategies over time.
CASE
After a few weeks of appropriate treatment, Mrs. Olivera, a patient with a pressure ulcer, remains in the hospital. The nurse manager reviews the
nursing documentation, specifically the patient‘s weekly wound measurements, for evidence that the wound is healing. The nurse manager
detects a large variance between the patient‘s wound measurements. On admission, Mrs. Olivera‘s wound measured 4 cm x 6 cm x 3 cm (length
x width x depth). A week later, the patient‘s wound was documented to measure 1.5 x 2.5 x 1, indicating the wound had decreased in size
dramatically. The third week the wound was documented as 5.5 x 3.5 x 2.5, indicating that the wound had worsened dramatically.
Such changes don‘t seem to make sense to the nurse manager. In questioning the staff about these measurement differences, the nurse
manager discovers that for the second week‘s measurements, the nurse reversed the measuring device and measured in inches rather than
centimeters. For the third week, another nurse documented the width as the length and the length as the width.
At the next staff meeting, the nurse manager brings a wound model so that the nurses can practice wound measurement. The manager reviews
that length is a head-to-toe or 12 o‘clock–to–6 o‘clock measurement, and that width is a side-to-side or 9 o‘clock–to–3 o‘clock measurement. She
also emphasizes the need to use metric measurements. As a result, Mrs. Olivera‘s wound is now consistently measured, demonstrating that the
facility‘s care of the patient is helping to heal the wound.
Minimizing the Recurrence of Ulcers
Achieving a closed wound is just the beginning of the struggle to prevent an ulcer from recurring.
Clinicians must emphasize and re-emphasize to patients and caregivers that measures to promote
healing and prevent recurrence are lifelong. Recurrence rates for adults have been reported as high as
56%, and 21% develop a new ulcer at a different site (WOCN, 2010). The most common factors
associated with recurrence are related to a lack of compliance with offloading the pressure area and
maintaining a healthy lifestyle, such as stopping smoking, maintaining a normal weight, and controlling
blood sugars if diabetic. Patient education regarding these factors is critical.

AVOIDABLE VERSUS UNAVOIDABLE PRESSURE ULCERS
Pressure ulcers are a global health concern because, for the most part, they are a costly, preventable
complication. But are all pressure ulcers preventable or avoidable? In the past, clinicians have argued
that pressure ulcers are not avoidable when the patient is too sick to be turned; when there are more vital
organs to worry about than the skin; or when it is too difficult, expensive, or there is not enough staff to
implement all preventative measures.
Yet as early as 2000, the U.S. Department of Health and Human Services stated that reducing pressure
ulcer incidence is an objective for all healthcare providers. In 2008, the Center for Medicare and
Medicaid Services (CMS) determined that hospital-acquired conditions could be reasonably prevented
with evidence-based guidelines. In support of this determination, CMS stopped reimbursing hospitals for
the treatment and care of pressure ulcers that were not present on admission.
Since then, it has been recognized that for some patients a pressure ulcer may be unavoidable. The
definition of an unavoidable pressure ulcer is one that develops in spite of the facility‘s best efforts at
prevention. The difference between avoidable and unavoidable pressure ulcers is based on whether or
not the treating facility was responsible in overseeing the provision of these actions:
 Evaluating the patient‘s clinical condition and pressure ulcer risk factors
 Defining and implementing interventions consistent with the patient‘s needs and goals and with recognized standards of practice
 Monitoring and evaluating the impact of the interventions
 Revising the interventions as appropriate
Thus, the topics discussed in this course—risk assessment, prevention, management, reevaluation, and
documentation—are the very factors used to determine if all that can be done for the patient has in fact
been done to prevent a pressure ulcer.

CONCLUSION
Pressure ulcers are alterations in skin integrity due to unrelieved pressure. Nearly all are considered
preventable, and this requires a full commitment by the healthcare facility and staff so that a pressure
ulcer will not occur.
There are many factors that contribute to the formation of a pressure ulcer, including comorbidities,
incontinence, poor nutrition, and advanced age, but the most significant risk factor is immobility. Patients
who are dependent on others for repositioning are at greatest risk of developing a pressure ulcer, for
nonhealing of an ulcer should it occur, and for the recurrence of an ulcer.
Improving the mobility of patients, or mitigating the effects of immobility, requires the assistance of many
in the healthcare team:
 The physical therapist, who teaches the patient, family, and staff how best to safely mobilize the patient
 The medical equipment department, that determines what equipment is available for the patient
 The social worker, who uncovers what resources are available to the patient
 Most of all, the bedside clinicians, whose role it is to assess all of the risk factors, to see that needed interventions are provided, and
to reassess outcomes frequently.
To do less puts all vulnerable patients in jeopardy.
Nursing Care, Prevention and Treatment of Decubitus Ulcers
The common areas of decubitus ulcer formation and prevention is a basic
nursing principle covered in nursing school curriculum (LVN/LPN or RN) and
most nursing assistant programs as well. Prevention consists of changing
position every 2 hours or more frequently if needed. This 2-hour time frame is
a generally accepted maximum interval that the tissue can tolerate pressure
without damage. Prevention also consists of protection and padding to
prevent tissue abrasion, and maintaining hydration, nutrition and hygiene.
The treatment for a decubitus ulcer involves keeping the area clean and
removing necrotic (dead) tissue, which can form a breeding ground for
infection. There are many procedures and products available for this purpose.
The use of antibiotics, when appropriate is also part of the treatment. Some
deep wounds even require surgical removal or debridement of necrotic tissue.
In some situations amputation may be necessary.
The second portion of the treatment involves removing all pressure from the
involved area(s) to prevent further damage of tissue and to promote healing.
Frequent turning is mandatory to alleviate pressure on the wound and to
promote healing. Along with cleaning, removal of dead tissue, and alleviating
pressure, the individual must have increased nutrition to allow for proper
healing of the wounds. Without all of these elements being in place, the
wounds will not heal and, in fact, will quickly worsen.
Prevention
The basic treatment of decubitus ulcers is prevention. Prevention cannot be
stressed too strongly. To this end, there are any number of devices designed
to protect and prevent the formation of decubitus ulcers. The decision of which
device to use is based on the location and severity of the wound. These
devices may be a Medicare/Medicaid/Insurance-covered item when medically
necessary. Most insurance's will cover any needed device, material, or
equipment necessary to prevent and treat decubitus ulcers. Prevention is the
most humane and cost effective approach to care.
Rheumatic Heart Disease
Rheumatic heart disease (RHD) is a condition in which permanent damage to heart valves is caused by rheumatic fever. Rheumatic fever
begins with a strep throat from streptococcal (STREP’to-KOK’al) infection. As many as 39% of patients with acute rheumatic fever may
develop varying degrees of pancarditis with associated valve insufficiency, heart failure, pericarditis, and even death.
With chronic rheumatic heart disease, patients develop valve stenosis with varying degrees of regurgitation, atrial dilation, arrhythmias, and
ventricular dysfunction. Chronic rheumatic heart disease remains the leading cause of mitral valve stenosis and valve replacement in adults
in many countries including in Indonesia.

 What are the symptoms of rheumatic heart disease?

The symptoms of rheumatic heart disease vary and damage to the heart often is not readily noticeable. When symptoms do appear, they
may depend on the extent and location of the heart damage. The symptoms of rheumatic heart disease vary and damage to the heart often
is not readily noticeable. When symptoms do appear, they may depend on the extent and location of the heart damage.
 Fever.
 Weight loss.
 Fatigue.
 Stomach pains.
 Joint inflammation – including swelling, tenderness, and redness over multiple joints. The joints affected are usually the larger joints in
the knees or ankles. The inflammation “moves” from one joint to another over several days.
 Small nodules or hard, round bumps under the skin.
 A change in your child’s neuromuscular movements (this is usually noted by a change in your child’s handwriting and may also include
jerky movements).
 Rash (a pink rash with odd edges that is usually seen on the trunk of the body or arms and legs).

 How to treat of rheumatic heart disease :

Medical therapy is directed toward eliminating the group A streptococcal pharyngitis (if still present), suppressing inflammation from the
autoimmune response, and providing supportive treatment for congestive heart failure. But the specific treatment for rheumatic heart disease
will be determined by your physician based on:
1. your overall health and medical history
2. extent of the disease
3. your tolerance for specific medications, procedures, or therapies
4. expectations for the course of the disease
5. your opinion or preference

Since rheumatic fever is the cause of rheumatic heart disease, the best treatment is to prevent rheumatic fever from occurring. Oral penicillin
V remains the drug of choice for treatment of group A streptococcal pharyngitis. When oral penicillin is not feasible or dependable, a single
dose of intramuscular benzathine penicillin G is therapeutic. For patients who are allergic to penicillin, administer erythromycin or a first-
generation cephalosporin.
Other options include clarithromycin for 10 days, azithromycin for 5 days, or a narrow-spectrum (first-generation) cephalosporin for 10 days.
To reduce inflammation, aspirin, steroids, or non-steroidal medications may be given. Surgery may be necessary to repair or replace the
damaged valve.

 Can Rheumatic Heart Disease be Prevented?

The best way to prevent rheumatic heart disease is to seek immediate medical attention to a strep throat and not let it progress to rheumatic
fever. The Nurses also have a role in prevention, primarily in screening school-aged children for sore throats that may be caused by Group A
streptococci(especially Group A β Hemolytic Streptococcus pyogenes).
Persons who have previously contracted rheumatic fever are often given continuous (daily or monthly) antibiotic treatments, possibly for life,
to prevent future attacks of rheumatic fever and lower the risk of heart damage.
Rheumatic Heart Disease
is a disease where it can damage the heart valves, such as leaks or strictures, particularly mitral valve (mitral stenosis) caused by rheumatic fever. This disease is
very dangerous because it caused the valves of the heart valve in the course of the disease process that begins with a throat injury.

Symptoms of Rheumatic Heart Disease :

 Joint inflammation : including swelling, tenderness, and redness over multiple joints. The joints affected are usually the larger joints in the knees or ankles.
The inflammation "moves" from one joint to another over several days.
 Small nodules or hard, round bumps under the skin.
 A change in your child's neuromuscular movements (this is usually noted by a change in your child's handwriting and may also include jerky movements).
 Rash (a pink rash with odd edges that is usually seen on the trunk of the body orarms and legs).
 Fever.
 Weight loss.
 Fatigue.
 Stomach pains.
The symptoms may resemble other conditions or medical problems. Always consult your child's physician for a diagnosis.

Diagnosis of Rheumatic Heart Disease (RHD)

Besides the presence of signs and symptoms that appear directly on the physical, the doctor will usually perform some lab tests that indicate, for example, routine
blood tests, Asto, CRP and throat culture. The most accurate survey is echocardiography do to see the status of valves and heart muscle

Treatment of RHD

The best treatment for rheumatic heart disease is prevention. Antibiotics can usually treat strep throat (a Streptococcus bacterial infection) and stop acute from
developing. Antibiotictherapy has sharply reduced the incidence and mortality rate of rheumatic fever and rheumatic heart disease.

Prevention of Rheumatic Heart Disease

There is no guaranteed way to prevent such problems, but still, you can do plenty of things to substantially reduce the chance of such bacterial infection and the
subsequent rheumaticcomplications. For example, Personal hygiene can play a very important role in this regard. The basic idea is to eliminate the chance of
getting affected with a strep throat. Besides that, if strep throat still occurs, you must seek immediate medical help from experts. Any delay in treatment can be
very dangerous for your heart health.

Complications Rheumatic Heart Disease

The list of complications that have been mentioned in various sources for Rheumatic heart disease includes:

 Endocarditic is inflammation of the inner lining of the heart.
 Bacterial endocarditic is the infection and inflammation of the inner layers of the heart, most commonly the valves cause by bacteria.
 Heart failure a syndrome classified by myocardial malfunction, heart failure can lead to deficient pump performance reduced cardiac output and to frank
heart failure and abnormal circulatory congestion. Congestion of systemic venous flow may end up in tangential edema and hepatomegaly; congestion of
pulmonary circulation may cause pulmonary edema, an acute, life-threatening emergency.

Nursing Diagnosis for Rheumatic Heart Disease

1. Risk for Decreased Cardiac Output

2. Hyperthermia

3. Imbalanced Nutrition, Less Than Body Requirements

4. Acute Pain
Activity intolerance related to imbalance between oxygen supply (delivery) and demand.

Goal :
Able to maintain / improve ambulation / activity.

Expected Outcomes :


 Reported an increase in activity tolerance (including daily activities).
 Indicates decrease in physiological signs of intolerance, such as pulse, respiration, and blood pressure is still within the normal range.
Nursing Intervention :

 Monitor vital sign (Blood Pressure, pulse, and respirations) during and after activity.
Rational : Cardiopulmonary manifestations result from attempts by the heart and lungs to supply adequate amounts of oxygen to the tissues.
 Assess patient ability to perform ADLs
Rational : Influences choice of interventions and needed assistance.
 Provide or recommend assistance with activities and ambulation as necessary, allowing client to be an active participant as much as possible.
Rational : Although help may be necessary, self-esteem is enhanced when client does some things for self.
 Suggest client change position slowly; monitor for dizziness.
Rational : Postural hypotension or cerebral hypoxia may cause dizziness, fainting, and increased risk of injury.
 Identify and implement energy-saving techniques
Rational : Encourages client to do as much as possible, while conserving limited energy and preventing fatigue.
 Instruct client to stop activity if palpitations, chest pain, shortness of breath, weakness, or dizziness occur.
Rational : Cellular ischemia potentiates risk of infarction, and excessive cardiopulmonary strain and stress may lead to decompensation and failure.

Risk for infection related to an inadequate secondary defenses (decreased hemoglobin leucopenia, or a decrease in granulocytes (inflammatory
response depressed)).

Goal :
Infection does not occur.

Expected Outcomes :


 Identify the behaviors to prevent / reduce the risk of infection.
 Improving wound healing, free of purulent drainage or erythema, and fever.
Nursing Intervention :

 Increase of good hand washing; by care givers and patients.
Rational: to prevent cross-contamination / bacterial colonization. Note: patients with severe anemia / aplastic can be risky due to the normal flora of the
skin.
 Maintain strict aseptic technique in the procedure / treatment of injuries.
Rational: reducing the risk of colonization / infection of bacteria.
 Provide skin care, perianal and oral carefully.
Rational: reducing the risk of damage to the skin / tissue and infection.
 Motivation changes in position / ambulation frequently, coughing and breathing exercises that deep.
Rational: to improve the ventilation of all lung segments, and help mobilizesecretions to prevent pneumonia.
 Increase adequate fluids.
Rational: to assist in the dilution of respiratory secretions to facilitate the spending and prevent stasis of body fluids such as respiratory and kidney.
 Monitor / limit visitors. Provide insulation if possible.
Rational: to limit exposure to the bacteria / infection. Protection of insulation required in aplastic anemia, when the immune response is disrupted.
 Monitor body temperature. Note the chills and tachycardia with or without fever.
Rational: the process of inflammation / infection require evaluation / treatment.
 Observe erythema / wound fluid.
Rational: indicators of local infection. Note: the formation of pus may not exist whengranulocytes depressed.
 Take specimens for culture / sensitivity as indicated (collaboration)
Rational: differentiate an infection, identify the specific pathogen and affect treatment options.
 Give a topical antiseptic; systemic antibiotics (collaboration).
Rational: propilaktik may be used to reduce colonization or for the treatment of local infection process.
for Osteomyelitis : Nursing Diagnosis forOsteomyelitis and Nursing Interventions for Osteomyelitis

Osteomyelitis is an infection of the bone. It can be caused by avariety of microbial agents (most common in staphylococcus aureus) and situations,
including:

 An open injury to the bone, such as an open fracture with the bone ends piercing the skin.
 An infection from elsewhere in the body, such as pneumonia or a urinary tract infection that has spread to the bone through the blood
(bacteremia, sepsis).
 A minor trauma, which can lead to a blood clot around the bone and then a secondary infection from seeding of bacteria.
 Bacteria in the bloodstream bacteremia (poor dentition), which is deposited in a focal (localized) area of the bone. This bacterial site in the
bone then grows, resulting in destruction of the bone. However, new bone often forms around the site.
 A chronic open wound or soft tissue infection can eventually extend down to the bone surface, leading to a secondary bone infection.

Symptoms of osteomyelitis

The symptoms of osteomyelitis can include:

 Pain and/or tenderness in the infected area
 Swelling and warmth in the infected area
 Fever
 Nausea, secondarily from being ill with infection
 General discomfort, uneasiness, or ill feeling
 Drainage of pus through the skin

Additional symptoms that may be associated with this disease include:

 Excessive sweating
 Chills
 Lower back pain (if the spine is involved)
 Swelling of the ankles, feet, and legs
 Changes in gait (walking pattern that is a painful, yielding a limp)


Nursing Diagnosis for Osteomyelitis

1. Acute pain related to inflammation and swelling
2. Impaired Physical Mobility related to pain and limitation of the load weight
3. Risk for Infection

Targets to be achieved:

1. Pain is reduced
2. Improvement of physical mobility within the limits of therapeutic
3. Infection control

Nursing interventions for Osteomyelitis

1. Immobilization of the affected area with a splint to reduce pain and muscle spasms.

2. Joints above and below the affected area should be made so that still can be moved according to the range yet gently. The wound itself is
sometimes very painful and must be handled carefully and slowly.

3. Elevate the affected area to reduce swelling and discomfort.

4. Monitor the affected extremity neurovascular status.

5. Do pain management techniques such as massage, distraction, relaxation, hypnosis to reduce pain perception and collaboration with medical for
providing analgesic.

6. Protect your bones by means of immobilization and avoid stress on the bone because bones become weak due to theinfection process.

The creatinine blood test measures the level of creatinine in the blood. This test is done to see how well your kidneys work.
Creatinine can also be measured with a urine test.
How the Test is Performed
A blood sample is needed.
How to Prepare for the Test
The health care provider may tell you to temporarily stop taking certain medicines that can affect the test. Medicines include:
 Aminoglycosides (for example, gentamicin)
 Cimetidine
 Heavy metal chemotherapy drugs (for example, cisplatin)
 Kidney damaging drugs such as cephalosporins (for example, cephalexin)
 Nonsteroidal anti-inflammatory drugs (NSAIDs)
 Trimethoprim
How the Test will Feel
When the needle is inserted to draw blood, some people feel moderate pain. Others feel only a prick or stinging sensation. Afterward, there may be
some throbbing or slight bruising. These soon go away.
Why the Test is Performed
Creatinine is a chemical waste product of creatine. Creatine is a chemical made by the body and is used to supply energy mainly to muscles.
This test is done to see how well your kidneys work. Creatinine is removed from the body entirely by the kidneys. If kidney function is not normal,
creatinine level increases in your blood. This is because less creatinine is released through your urine.
The creatinine level also varies according to a person's size and muscle mass.
Normal Results
A normal result is 0.7 to 1.3 mg/dL for men and 0.6 to 1.1 mg/dL for women.
Women usually have a lower creatinine level than men. This is because women usually have less muscle mass than men.
The examples above are common measurements for results of these tests. Normal value ranges may vary slightly among different laboratories. Some
labs use different measurements or test different samples. Talk to your doctor about the meaning of your specific test results.
What Abnormal Results Mean
Higher than normal level may be due to:
 Blocked urinary tract
 Kidney problems, such as kidney damage or failure, infection, or reduced blood flow
 Loss of body fluid (dehydration)
 Muscle problems, such as breakdown of muscle fibers (rhabdomyolysis)
 Problems during pregancy, such as seizures (eclampsia), or high blood pressure caused by pregnancy (preeclampsia)
Lower than normal level may be due to:
 Conditions involving the muscles and the nerves that control them (myasthenia gravis)
 Muscle problems, such as late stage muscle loss (muscular dystrophy)
There are many other conditions for which the test may be ordered, such as high blood pressure, diabetes or medication overdose. Your health care
provider will tell you more, if needed.
Risks
There is very little risk involved with having your blood taken. Veins and arteries vary in size from one patient to another and from one side of the body
to the other. Taking blood from some people may be more difficult than from others.
Other risks associated with having blood drawn are slight but may include:
 Excessive bleeding
 Fainting or feeling light-headed
 Hematoma (blood accumulating under the skin)
 Infection (a slight risk any time the skin is broken)
Alternative Names
Serum creatinine
Creatinine: A chemical waste molecule that is generated from muscle metabolism. Creatinine is produced from creatine, a molecule of major
importance for energy production in muscles. Approximately 2% of the body's creatine is converted to creatinine every day. Creatinine is
transported through the bloodstream to the kidneys. The kidneys filter out most of the creatinine and dispose of it in the urine.
Although it is a waste, creatinine serves a vital diagnostic function. Creatinine has been found to be a fairly reliable indicator of kidney
function. As the kidneys become impaired the creatinine will rise. Abnormally high levels of creatinine thus warn of possible malfunction or
failure of the kidneys, sometimes even before a patient reports any symptoms. It is for this reason that standard blood and urine tests
routinely check the amount of creatinine in the blood.
Normal levels of creatinine in the blood are approximately 0.6 to 1.2 milligrams (mg) per deciliter (dl) in adult males and 0.5 to 1.1 milligrams
per deciliter in adult females. (In the metric system, a milligram is a unit of weight equal to one-thousandth of a gram, and a deciliter is a unit
of volume equal to one-tenth of a liter.) Muscular young or middle-aged adults may have more creatinine in their blood than the norm for the
general population. Elderly persons, on the other hand, may have less creatinine in their blood than the norm. Infants have normal levels of
about 0.2 or more, depending on their muscle development. A person with only one kidney may have a normal level of about 1.8 or 1.9.
Creatinine levels that reach 2.0 or more in babies and 10.0 or more in adults may indicate the need for a dialysis machine to remove wastes
from the blood.
Certain drugs can sometimes cause abnormally elevated creatinine levels.
Phosphate buffered saline (abbreviated PBS) is a buffer solution commonly used in biological research. It is a water-based salt solution
containing sodium phosphate, sodium chloride and, in some formulations, potassium chloride and potassium phosphate. The osmolarity and
ion concentrations of the solutions match those of the human body (isotonic).
PBS has many uses because it is isotonic and non-toxic to most cells. These uses include substance dilution and cell container rinsing. PBS
with EDTA is also used to disengage attached and clumped cells. Divalent metals such as zinc, however, cannot be added as this will result
in precipitation. For these types of applications, Good's buffers are recommended.

So you‘ve never heard of an acute coronary syndrome. But what aboutheart attack, or unstable angina? Those well-known conditions are both acute coronary
syndromes, an umbrella term for situations where the blood supplied to the heart muscle is suddenly blocked.
―This is an absolute medical emergency. Something dramatic, right this minute is going on in the arteries that is hurting the blood flow to the heart,‖ said Ann
Bolger, M.D., a cardiologist at San Francisco General Hospital and a member of the American Heart Association‘s Council on Clinical Cardiology.

The blockage can be sudden and complete, or it can come and go – clot, break open, then clot again. ―In either case, the heart tissue is dying, even if it‘s just a
few cells or a whole big section of the heart,‖ Bolger said.

Doctors use the broad term regularly, but usually only among themselves and in the medical literature. ―It‘s like describing a North American state rather than just
saying Texas,‖ Bolger said. ―I don‘t think too many doctors say, ‗You‘re having an acute coronary syndrome.‘ They say, ‗You‘re having a heart attack.‘‖

What are the symptoms?
Chest pain or discomfort may immediately signal to you that something‘s wrong with your heart. Other symptoms, however, may leave you unsure of what‘s wrong.
Take note of these common signs of an acute coronary syndrome:
 Chest pain or discomfort, which may involve pressure, tightness or fullness
 Pain or discomfort in one or both arms, the jaw, neck, back or stomach
 Shortness of breath
 Feeling dizzy or lightheaded
 Nausea
 Sweating
These symptoms should be taken seriously. If you experience chest pain or other symptoms, call 9-1-1 immediately. ―People are in denial and they‘re sitting there
thinking, ‗This can‘t really be happening to me,‘‖ Bolger said. ―We want them to feel entitled to call 9-1-1. They‘re not being alarmist.‖

Chest pain caused by acute coronary syndromes can come on suddenly, as is the case with a heart attack. Other times, the pain can be unpredictable or get
worse even with rest, both hallmark symptoms of unstable angina. People who experience chronic chest pain resulting from years of cholesterol buildup in their
arteries can develop an acute coronary syndrome if a blood clot forms on top of the plaque buildup.

How is it diagnosed and treated?
To determine what‘s causing your symptoms, a doctor will take a careful medical history and give you a physical examination. If the doctor suspects an acute
coronary syndrome, the following tests will be performed:
 A blood test can show evidence that heart cells are dying.
 An electrocardiogram (ECG or EKG) can diagnose an acute coronary syndrome by measuring the heart‘s electrical activity.
If tests confirm blood flow to the heart has been blocked, doctors will work quickly to reopen the artery. ―Minute by minute, the heart is accumulating irreversible
damage. So time is myocardium – myocardium being the heart muscle itself,‖ Bolger said.

At San Francisco General Hospital, the goal is to have the artery reopened within an hour of the patient entering the hospital, Bolger said. Generally, patients do
best when the artery is reopened within four hours of the first symptoms.

Treatment for acute coronary syndrome includes medicines and a procedure known as
angioplasty, during which doctors inflate a small balloon to open the artery (View an
illustration of coronary arteries). A stent, a wire mesh tube, may be permanently placed
in the artery to keep it open. For hospitals not equipped to do angioplasty quickly, drugs
may be used to dissolve blood clots, but more hospitals are making the procedure
available in a timely manner, Bolger said.

Am I at risk?
Acute coronary syndromes, just like heart failure and stroke, are much more likely in
people who have certain risk factors. These include:
 Smoking
 High blood pressure
 High blood cholesterol
 Diabetes
 Physical inactivity
 Being overweight or obese
 A family history of chest pain, heart disease or stroke
Your primary care doctor can help you understand your personal risk and what you can do about it. ―[The physician] should also be the one to say, ‗By the way, if
you ever have any of these symptoms, I want you to call 9-1-1,‘‖ Bolger said. ―If someone has told you that in advance, you‘re much more likely to do it.‖
fasting blood glucose in a person without diabetes should be 110 mg/dL or less.
 If the result is higher than 110 mg/dL but less than 126 mg/dl, the diagnosis of impaired
fasting glucose or pre-diabetes can be made.
 If the result is 126 mg/dL or higher, then another test should be done to confirm a diagnosis of
diabetes

An MRI (magnetic resonance imaging) scan is an imaging test that uses powerful magnets and radio waves to create pictures of the body. It does not
use radiation (x-rays).
Single MRI images are called slices. The images can be stored on a computer or printed on film. One exam produces dozens or sometimes hundreds
of images.
For more information, see the specific MRI topics:
 Abdominal MRI
 Chest MRI
 Cranial MRI
 Heart MRI
 Spine MRI
How the Test is Performed
You may be asked to wear a hospital gown or clothing without zippers or snaps (such as sweatpants and a t-shirt). Certain types of metal can cause
blurry images.
You will lie on a narrow table, which slides into a large tunnel-shaped scanner.
Some exams require a special dye (contrast). Most of the time, the dye will be given through a vein (IV) in your hand or forearm before the test. The
dye helps the radiologist see certain areas more clearly.
Small devices, called coils, may be placed around the head, arm, or leg, or other areas to be studied. These help send and receive the radio waves,
and help the quality of the images.
During the MRI, the person who operates the machine will watch you from another room. The test lasts about 30 to 60 minutes, but may take longer.
How to Prepare for the Test
You may be asked not to eat or drink anything for 4 to 6 hours before the scan.
Tell your doctor if you are afraid of close spaces (have claustrophobia). You may be given a medicine to help you feel sleepy and less anxious, or your
doctor may suggest an "open" MRI, in which the machine is not as close to the body.
Before the test, tell your health care provider if you have:
 Artificial heart valves
 Brain aneurysm clips

 Heart defibrillator or pacemaker
 Inner ear (cochlear) implants
 Kidney disease or dialysis (you may not be able to receive contrast)
 Recently placed artificial joints
 Vascular stents
 Worked with sheet metal in the past (you may need tests to check for metal pieces in your eyes)
Because the MRI contains strong magnets, metal objects are not allowed into the room with the MRI scanner:
 Items such as jewelry, watches, credit cards, and hearing aids can be damaged.
 Pens, pocketknives, and eyeglasses may fly across the room.
 Pins, hairpins, metal zippers, and similar metallic items can distort the images.
 Removable dental work should be taken out just before the scan.
How the Test Will Feel
An MRI exam causes no pain. If you have difficulty lying still or are very nervous, you may be given a medicine to relax you. Too much movement can
blur MRI images and cause errors.
The table may be hard or cold, but you can request a blanket or pillow. The machine produces loud thumping and humming noises when turned on.
You can wear ear plugs to help reduce the noise.
An intercom in the room allows you to speak to someone at any time. Some MRIs have televisions and special headphones that you can use to help
the time pass.
There is no recovery time, unless you were given a medicine to relax. After an MRI scan, you can resume your normal diet, activity, and medications.
Why the Test is Performed
Having MRIs with other imaging methods can often help your doctor make a diagnosis.
MRI images taken after a special dye (contrast) is delivered into your body may provide extra information about the blood vessels.
An MRA, or magnetic resonance angiogram, is a form of magnetic resonance imaging, that creates three-dimensional pictures of blood vessels. It is
often used when traditional angiography cannot be done.
Normal values
A normal result means the body area being studied looks normal.
What Abnormal Results Mean
Results depend on the part of the body being examined and the nature of the problem. Different types of tissues send back different MRI signals. For
example, healthy tissue sends back a slightly different signal than cancerous tissue. Consult your health care provider with any questions and
concerns.
Risks
MRI does not use ionizing radiation. No side effects from the magnetic fields and radio waves have been reported.
The most common type of contrast (dye) used is gadolinium. It is very safe. Allergic reactions rarely occur. However, gadolinium can be harmful
to people with kidney problems who are on dialysis. Tell your health care provider before the test if you have kidney problems.
The strong magnetic fields created during an MRI can cause heart pacemakers and other implants not to work as well. The magnets can also cause
a piece of metal inside your body to move or shift.
Alternative Names
Magnetic resonance imaging; Nuclear magnetic resonance (NMR) imaging