The management of chronic wounds is a significant area of the workload for just about any nurse caring for elderly prone people since these patients will be more susceptible to the conditions that can lead to chronic wounding. Long-term wounds like pressure ulcers needs a detailed and specific treatment programs depending upon the type of the wound and the circumstances of the patient. The experience of experiencing a pressure ulcer can lead to the loss of a patient's sense of personal. Exudation and malodour may lead to social problems which, along with skin area problems, may lower a patient's quality of life. Hence Pressure ulcers have to be prevented as far as possible in all care options. Pressure ulcer management entails treating an infection, providing a damp wound-healing environment and choosing the correct dressing. Various studies on this issue have found that a multidisciplinary way is the successful mode for care of patients with pressure ulcers. This article is a review of the many studies assessing the guidelines of nursing management of pressure ulcers. New medical interventions and pressure-redistributing devices in rigorous care models, and specific risk factors impacting critically sick patients, imply that different factors must be studied into consideration in stopping pressure ulcers.
A pressure ulcer can be an area of epidermis especially the regions of superficial or deep- tissue that has been ruined by pressure, friction shear or a combination of the factors There are lots of factors attributing to the chance of pressure ulcers and the major ones are fatness, immobilisation and malnutrition while old age, malignancy, venous insufficiency, diabetics and background contribute to hold off in healing. Pressure ulcers are found mainly in bedridden patients with vertebral harm etc pressure ulcers develop because of this of prolonged periods of immobility during unrelieved pressure which compresses tissue that overlie bony prominences. After the pressure ulcer is rolling out, it tends to deteriorate owing to the patient's physical characteristics, such as extreme bony prominence, and poor condition in general. (Sanada et al. , 2008).
The nature of the unnecessary pressure is important in the introduction of pressure ulcers. The main element in pressure ulcer development is abnormal cells pressure that inhibits the normal supply of bloodstream to the affected area. The severity of skin and injury will depend on how long the patient has been exposed to these excess pressures. In the words of Betsy Myers, elimination is the foremost treatment for pressure ulcers. By being aware of the risk factors for pressure ulcer development, examining for changes in risk factors on a continuing basis, and addressing risk factors, the incidence of pressure ulcers can be markedly reduced.
Several risk factors have been recognized for the development of pressure ulcers and are categorised into extrinsic and intrinsic factors. Extrinsic factors include program pressure, shearing makes, friction and moisture content. Intrinsic factors will be the nutritional position of the patient, patient years, immobility, incontinence, circulatory factors, and neurological disease. Three main mechanical factors are thought to contribute in the introduction of pressure ulcers: pressure, friction and shear. Pressure ulcers are present in patients with extensive immobility and recovery is postponed for these patients anticipated to numerous reasons like the accompanying medical problems like infections stretching the hospitalization period for patients. Methods to measure immobility aren't generally available in professional medical settings.
A successful wound management should include evaluation, planning, management, reassessment, admission, transfer, reporting and audit. As per EPUAP suggestions (2010), all patients with wounds should be reassessed and documented at least regular and the procedure methods and any modifications to be reviewed with the patient. Elimination of pressure ulcers helps reduce patient suffering. The first rung on the ladder in pressure ulcer avoidance is to identify those patients in danger and a number of risk examination tools have been developed since the 1960s. It is important that an examination tool is appropriate for the precise patient setting where it can be used.
A study conducted by Ingela Henoch (2003) provides following details on risk examination tools for pressure ulcers. Accordingly, risk assessment tools are developed from nursing experience and research on the sources of pressure ulcers. A proper risk assessment tool should assess only necessary factors, facilitate the nurse's work, be easy to use, require little training, have clear management guidelines and stop pressure ulcers. The major examination tools to study the chance factors of pressure ulcers are the Norton range, the Braden Level and the Waterlow size.
The original Norton range, used since the 1960s, includes physical express, mental state, freedom, activity and incontinence but excluded era and malnutrition because the scale was developed for use with the elderly and was considered a part of general physical condition (Norton, 1989). The Norton level is modified and the modern version is known as the changed Norton level. The Braden range focuses on calculating intensity and duration of pressure, and level of sensitivity of the patient's skin area (Bergstrom et al, 1987). The Waterlow scale was compiled in Great Britain in 1984 and contains two parts, one measuring pressure ulcer risk and the other outlining a prevention and treatment policy (Waterlow, 1991). The level includes several factors particularly directed to acutely sick patients that are omitted in the Norton level. In her study testing the various scales for their ability to identify differences between your patient categories with and without pressure ulcers, Ingela concludes locating the size which became HoRT size to be superior in regards to to statistical value and validity. Consistency was dependant on evaluating the scale's predictions with the real amounts of patients with and without ulcers.
Sensitivity and specificity, and procedures produced from these, are epidemiological tools in assessing the predictive validity of diagnostic testing tests. The risk examination tools are cured as if they can be diagnostic screening checks, while in contrast with such testing tests, risk analysis scales aren't designed to identify the lifestyle of pressure ulcers, but to recognize the risk that pressure ulcers will occur.
The old expressing 'prevention is better than cure' is apt in the case of pressure ulcers and the probability a patient will develop pressure ulcer can be checked out if proper precautionary measures are utilized. Patients identified as being at risk will establish pressure ulcers only when preventive measures are unsuccessful. According to Laat et al's study, use of effective protection will alter the level of sensitivity and specificity of the chance assessment size. Laat et al confirms that there is still no research for a valid risk examination tool in critically unwell patients. Generally, Laat et al advises prevalence and occurrence studies to be designed and performed in accordance with the EPUAP rules and also call for a well-designed research on the epidemiological aspects, risk factors and risk evaluation of pressure ulcers in critically ill patients to get more insight in to the nature and degree of this problem.
Depending on various characteristics, pressure ulcers are classified under the International NPUAP- EPUAP Pressure Ulcer Classification System. Appropriately there are 4 levels (stage or category) from 1 to 4 and their characteristics are the following:
GRADE 1: Non-blanchable erythema of intact skin area; Discolouration of the skin, heat, oedema, induration or hardness can even be used as signals, particularly on people with darker pores and skin.
GRADE 2: partial thickness skin damage including epidermis or dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister.
GRADE 3: full width skin loss relating damage to or necrosis of subcutaneous cells that may increase down to, but not through, underlying fascia
GRADE 4: extensive destruction, tissues necrosis, or harm to muscle, bone or aiding buildings with/without full width skin damage.
Pressure ulcer level should be saved using the EPUAP classification system and everything pressure ulcers graded 2 and above should be noted as a local clinical event.
A failure to correctly evaluate and treat wounds will lead to failing to heal. It's important that a competent specialist undertakes the assessment process and programs the care. An effective wound management should include analysis, planning, management, reassessment, entrance, transfer, confirming and audit. According to EPUAP all patients with wounds should be reassessed and recorded at least weekly and the procedure methods and any modifications to be reviewed with the individual.
As Karen's (2005) details in her publication, the previous practice of pressure ulcer management was called back spherical process which engaged nurses washing and massaging the pressure areas of bedfast patients and making use of a variety of lotions, products, powder, natural oils and spirits so that they can prevent break down of the skin. If a pressure ulcer were that occurs then treatments varied. They included: lying down the patient on their side to lessen pressure and administering oxygen, by positioning an oxygen cover up above the ulcer to maintain an arid environment; placing a dressing of egg white within the afflicted area, with the idea that it would mend the ulcer because of the health proteins content of the egg.
The treatment needs of a pressure ulcer change as time passes, in terms of both curing and deterioration. Treatment strategies should be consistently re-evaluated predicated on the current status of the ulcer. All patients with wounds will need to have a holistic evaluation, including environment, cause, location, site, dimensions, exudates amount and type, healthy status, local signs or symptoms of infections, pain, wound appearance, encircling skin, undermining/ tracking, odour, analysis of the skin as a sensory organ and the patient's knowledge and understanding of their wound and basic condition. The wound examination should be documented on a proper wound analysis tool, within a day of entrance to a medical center setting and within one week of referral to primary health care.
Cleansing and Wound Dressing:
Likewise, special health care and research to be achieved before deciding on the cleansing agents to be used and the modes of wound dressing to be made and this differs in different cases. Wounds should only be cleansed when they are grubby, with either warm normal saline or tap water, and not on a regular basis. Regarding pressure ulcer the wound will be cleansed if there are any obvious signs of debris or if the ulcer is polluted with bodily fluids. EPUAP advises that antiseptics and antibiotics shouldn't be regularly used, however they may be looked at when bacterial lots have to be handled or until inflammation is reduced.
Positioning and Repositioning:
Zena et al's (EWMA 2010) analysis agrees to the fact that repositioning is an important component and is also advocated to be the best strategy in the management of the pressure ulcer patient. There are a number of interventions necessary for the management of a pressure ulcer patient like healthy care, pressure reducing/ relieving surfaces and epidermis and wound care.
Positioning of patients who spend significant periods of time in a seat or wheelchair should consider, circulation of weight, postural position and support of foot.
Pressure-redistributing mattresses or other pressure redistributing options in mixture with body repositioning are the primary preventive steps for standard and critically unwell patients. Regularly turning immobilised critically sick patients every two hours is the accepted standard of practice, yet it isn't practical all the times & most critically ill patients aren't repositioned according to the standard. In the case of patients with pressure ulcers, instead of the standard medical center foam mattress, Higher- specification foam mattresses should be preferred. In an in depth review conducted by Laat et al (2006), they could find no superior device than a higher specification foam bed for Pressure ulcer patients. Pressure ulcers are a significant problem for hospitalised patients. Effective management of patients vulnerable to or with pressure ulcers is the main element to attaining good clinical final results. While pressure-redistributing areas can assist in the management of patients vulnerable to pressure ulceration, there may be little available specialized medical evidence on which is best suited.
The presence of the wound could cause psychological distress for some patients and therefore effective communication with the individual is vital.
Since pressure ulcers appear in patients who are immobile in majority cases of bed ridden patients, event of the same is known as to be always a medical problem. Nurses are considered to be in charge of the examination and prevention of pressure ulcers and the role of Doctors come only secondary to the role of your nurse in this particular case. All the reviews and in depth studies on the pressure ulcer reveals the need of any interdisciplinary methodology for the management of any pressure ulcer taking part almost all level of professionals like doctors, nurses, therapists, dieticians, porters etc. It is the first of all obligation of an nurse to conduct ongoing, repeated analysis of risk factors of pressure ulcers since early detection and treatment are essential for the treatment procedure.
As Julie (EWMA 2009) points out that current medical documents of pressure ulcer protection and management is not satisfactory which risk assessment tools although not perfect do have a job to try out in the identification of those vulnerable to pressure ulceration by raising consciousness. Reporting and high quality documents is essential to the process of reduction in the incidence and prevalence of pressure ulcers. In the words of Karen (2005), an essential feature for the prevention of pressure ulcers is accurate and early id of patients at risk. Risk diagnosis tools are supposed as part of holistic assessment rather than to replace clinical judgment. The majority of patients accepted to a attention environment, including those patients who are being nursed in a community setting, should be evaluated, regardless of their age, gender or weight, and the results documented. If a patient is assessed as being vulnerable, then preventative measures should be put in place immediately and recorded. Failure to take action will be viewed as carelessness in the area of the practitioner, as harming the individual and may be viewed as a breach of human rights.
According to Irene (2010), goals for pressure ulcer avoidance require the selection of a bed which has a pressure redistribution surface such as air bladders, high-density foam, or alternating pressure surfaces. Careful and consistent skin assessments, frequent repositioning, managing wetness, and maximizing nutritional support are common interventions for prevention of pressure ulcers. Progressive flexibility techniques and repositioning techniques used to avoid pressure ulcers are designed to promote the best benefits while stopping dangerous difficulties.
Evaluating the Japanese Government's new motivation system when planning on taking care of high risk patients, Sanada et al (2010) is of the thoughts and opinions that for a powerful strategy on pressure ulcer management, we need to focus on recruiting, not on materials and devices.