DPP-NUR-ADM-0002-VERSION-03

[Audio] AL HARIQ GENERAL HOSPITAL NURSING DEPARTMENT PREVENTION OF PRESSURE ULCER DPP-NR-059-VERSION 03.

[Audio] DEFINITIONS PRESSUE ULCER: An area of skin that breakdown due to unrelieved pressure resulting to damage in the underlying tissue. It can be prevented by relieving pressure, positioning patient, using pressure relieving devices, improving mobility, sensory perception, tissue perfusion, and nutritional status, reducing friction, shearing force and minimizing irritating moisture..

[Audio] DEFINITIONS Braden Scale: – Tool used to determine the risk of developing PU among patients age above 8 years old. – Includes 6 subscales – Score of 19 or higher- No Risk – 15-18 Low Risk – 13-14 Moderate Risk – 10-12 High Risk – 9 & Below Very High.

[Audio] DEFINITIONS Braden Q Scale: –Tool used to determine the risk of developing PU among pediatric patients (age above 1 month to 8 years old) –Modification of the Adult Braden Scale –Includes 7 subscales –Score of 7- at highest risk –Score of 28- no risk.

[Audio] The SUB SCALES 1. Mobility 2. Activity 3. Sensory Perception 4. Moisture 5. Friction and Shear 6. Nutrition 7. Tissue Perfusion/Oxygenation.

[Audio] POLICY Pressure care is compulsory for all high risk patient and admitted patients with HAPU. Assessment and maintenance of patient skin integrity and prevention of pressure ulcers require diligent nursing care and skill..

[Audio] POLICY Pressure ulcer risk assessment scale is used upon admission, every shift, and if there is any changes in the patient condition to identify the patient at high-risk for pressure ulcer..

[Audio] PROCEDURES 1. Inspect and assess the skin every shift especially bony prominences and use the pressure ulcer assessment score every shift, and if there is any changes in the patient condition to identify the patient at high-risk for pressure ulcer. 2. Wash skin with mild soap. Rinse and dry, moisturize with lotion. 3. Avoid massaging the are with redness. 4. Clean and dry promptly for an incontinent patient, and put under pads or protective clothing to absorb and dry moisture quickly..

[Audio] PROCEDURES 5. Turn and reposition the patient at least every 2 hours unless contraindicated using the turning record..

[Audio] PROCEDURES 6. Use lifting devices ( such as lifter or bed linens) to move the patient, do not drag during transfer or change position. Use air mattress. 7. Advice patients sitting on a wheelchair to shift weight frequently and to rise for a few seconds every 15 minutes while sitting. 8. Obtain nutritional assessment data including serum albumin level, total protein level, hemoglobin and weight. 9. Improve nutritional status and maintain positive nutritional balance, high protein diet, vitamins, and protein supplement, iron preparation..

[Audio] PROCEDURES 10. Encourage ambulation and exercises. 11. Educate patient and family about prevention of pressure ulcers. 12. Document assessment accurately in the nurses notes..

[Audio] The most common sites for pressure ulcers are the sacrum, heels, ischium, tuberosities, greater trochanters and lateral malleoli..

[Audio] AL HARIQ GENERAL HOSPITAL NURSING DEPARTMENT MANAGEMENT OF PRESSURE ULCERS IPP-NR-033-VERSION 03.

[Audio] Identify any patient characteristics that might be risk factors for pressure ulcer formation.  Paralysis, or immobilization caused by restrictive devices  Sensory loss (e.g., hemiplegia, spinal cord injury)  Circulatory disorders (e.g., diabetes mellitus)  Fever  Anemia  Malnutrition  Incontinence  Heavy sedation and anesthesia.

[Audio] Identify any patient characteristics that might be risk factors for pressure ulcer formation.  Heavy sedation and anesthesia  Age  Dehydration  Edema  Existing pressure ulcers  History of pressure ulcer.

[Audio] POLICY When pressure ulcer develops, the patient becomes vulnerable to pain, infection and other complication. Therefore, the nurse plays a vital role in helping to heal pressure ulcer to reestablish the body's natural defenses through a plan of therapeutic interventions designed according to individualized need of the patient based on developmental stages of pressure ulcer and patient's level of health..

[Audio] POLICY Prevention of infection and cross contamination is a top priority in managing pressure ulcers. Determining the stages of pressure ulcers serves as an important tool to the type of treatment. Cleaning, debridement and dressing are three essential components of local pressure ulcer care..

[Audio] POLICY Cleaning – involves rinsing or irrigating the ulcer with a cleaning solution. 1. Remove the dead tissues, wound debris and old dressing materials at each dressing change. 2. Avoid use of soap or lotion. 3. Avoid hydrogen peroxide and povidone iodine. 4. Use normal saline as the typical solution..