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Yogananda Acuyong

Group A2

1. Clinical practice ng managment of:

a. bed sores
Adults: Risk Assessment

significantly limited mobility (for example, people with a spinal cord injury)
significant loss of sensation
a previous or current pressure ulcer
nutritional deficiency
the inability to reposition themselves
significant cognitive impairment

Skin Assessment

skin integrity in areas of pressure

colour changes or discoloration
variations in heat, firmness and moisture (for example, because of incontinence,
edema, dry or inflamed skin)


Repositioning every 2 hours

Encourage adults who have been assessed as being at risk of developing a pressure ulcer
to change their position frequently and at least every 2 hours. If they are unable to reposition
themselves, offer help to do so, using appropriate equipment if needed. Document the
frequency of repositioning required.
Use of egg foam matresses
Do not offer skin massage or rubbing to adults to prevent a pressure ulcer.
Offer nutritional supplements specifically to prevent a pressure ulcer in adults whose nutritional intake is
Offer subcutaneous or intravenous fluids specifically to prevent a pressure ulcer in adults whose hydration status
is inadequate.
Barrier creams- Consider using a barrier preparation to prevent skin damage in adults who are at high risk of
developing a moisture lesion or incontinence-associated dermatitis, as identified by skin assessment
Debridment - Assess the need to debride a pressure ulcer in adults, taking into consideration: the amount of
necrotic tissue the grade, size and extent of the pressure ulcer patient tolerance any comorbidities.

b. leg ulcers
1. Elevation of the limb - The higher the leg, the lower the pressure in the leg veins. If the foot is elevated above
the heart then the pressure in the foot drops to a normal level. Put your legs up whenever you can and as high as
you are able-the arm of the sofa is good. Elevate the lower end of your bed (6 inches or so) so that when in bed
your feet are a little higher than your head. You can use some old books for this.
2. Compression bandaging or stockings -In order to keep the pressure in the leg veins at the ankle low when you
are standing up, you will be treated with compression bandaging or stockings. Several layers of bandages may be
required to get the necessary pressure to control the veins. Once the ulcer is healed, compression stockings are
usually necessary to prevent the ulcer from returning. These stockings need to be specially fitted and are much
stronger than ordinary support tights.
3. Dressings -Use a number of different dressings under the bandages depending on the state of the ulcer itself.
These dressings may well change as the ulcer progresses
4. Surgery - Very occasionally, for the largest or very resistant ulcers either a skin graft or an operation on the veins
may be necessary. If your ulcer is due to varicose veins then these may be treated, usually once the ulcer has

Prevention from reoccuring:

Wear compression stockings (or bandages in a few severe cases) at all times during the day.
Elevate the legs whenever possible.
Keep the skin in good condition by using plenty of moisturising cream to prevent dryness.
Weight loss, fresh fruit, exercise and stopping smoking are also vital to help heal your ulcer as well as for
your general health.
Clean the SURROUNDING SKIN General care of the skin surrounding an ulcer is essential to maintain skin
integrity and minimise the risk of further ulceration. The peri-ulcer skin should be treated routinely with a bland
emollient, and ulcer margins should be coated with a barrier preparation to prevent maceration of surrounding

How long will it take the ulcer to heal?

It has usually taken many years for the venous disease to cause the ulcers, so it is not surprising that theulcers
may take a fairly long time to heal. Although most venous ulcers will heal in 3-4 months, a small proportion will
take considerably longer.

2.Common site of:

a. pressures ulcer

The most common sites are the back of the head and ears, the shoulders, the elbows, the lower back and
buttocks, the hips, the inner knees, and the heels. Pressure sores may also form in places where the skin folds over itself.
And they can occur where medical equipment puts pressure on the skin.

b. diabetes mellitus (Lower extremity; leg and foot)

Common Site: plantar surface of foot (metatarsal heads and midfoot), toes (dorsal interphalangeal joints or distal tip).
A result of various factors, such as mechanical changes in conformation of the bony architecture of the foot, peripheral
neuropathy, and atherosclerotic peripheral arterial disease, all of which occur with higher frequency and intensity in the
diabetic population.
Diabetic ulcer of the medial aspect of left first toe
before and after appropriate wound care. Diabetic
ulcer of left fourth toe associated with mild cellulitis.

3. Non healing wounds of diabetic patient

Blood Glucose Levels
It all starts here. An elevated blood sugar level stiffens the arteries and causes narrowing of the blood vessels. The effects
of this are far-reaching and include the origin of wounds as well as risk factors to proper wound healing.
Poor Circulation
Narrowed blood vessels lead to decreased blood flow and oxygen to a wound. An elevated blood sugar level decreases
the function of red blood cells that carry nutrients to the tissue. This lowers the efficiency of the white blood cells that fight
infection. Without sufficient nutrients and oxygen, a wound heals slowly.
Diabetic Neuropathy
When blood glucose levels are uncontrolled, nerves in the body are affected and patients can develop a loss of sensation.
This is called diabetic neuropathy. When there is a loss of sensation, patients cannot feel a developing blister, infection or
surgical wound problem. Because a diabetic patient may not be able to feel a change in the status of a wound or the
actual wound, the severity can progress and there may be complications with healing.
Immune System Deficiency
Diabetes lowers the efficiency of the immune system, the body's defense system against infection. A high glucose level
causes the immune cells to function ineffectively, which raises the risk of infection for the patient. Studies indicate that
particular enzymes and hormones that the body produces in response to an elevated blood sugar are responsible for
negatively impacting the immune system.
With a poorly functioning immune system, diabetics are at a higher risk for developing an infection. Infection raises many
health concerns and also slows the overall healing process.
Left untreated, infection can heighten the risk of developing gangrene, sepsis or a bone infection like osteomyelitis.

To keep an ulcer from becoming infected, it is important to:

keep blood glucose levels under tight control;

keep the ulcer clean and bandaged;
cleanse the wound daily, using a wound dressing or bandage; and
avoid walking barefoot.

There are several key factors in the appropriate treatment of a diabetic foot ulcer:

Prevention of infection
Taking the pressure off the area, called off-loading
Removing dead skin and tissue, called debridement
Applying medication or dressings to the ulcer
Managing blood glucose and other health problems

The key to successful wound healing:

Lowering blood sugar

Appropriate debridement of wounds
Treating any infection
Reducing friction and pressure
Restoring adequate blood flow