The document discusses questions and answers about pressure ulcers (bed sores). It begins by asking why they occur frequently in hospitals and ICUs, noting it may be because caregivers focus on other illnesses rather than the skin. It then addresses that immobility is the most common reason patients develop pressure ulcers. Risk factors like incontinence, impaired mobility, and malnutrition are examined. Prevention strategies involve regular repositioning, managing moisture, and relieving pressure on bony areas.

3. Some Question about Bed Sore
Q.1 Why dose many pressure ulcers occur in our hospitals,
especially in our "high-tech" ICUs?
Q2. What is the most common reason a patient develops a
pressure ulcer?
Q. 3 You are assigned five patients on your nursing unit. Which
patient is at most risk for pressure ulcers
Q.4 Which of the following interventions is most appropriate for
preventing excessive heel pressure?

4.  To know Definition
 To Know Risk Factors
 Pathophysiology
 Common Site of Bed Sore
 Classification of Bed Sore
 Complication Of Bed sore
 Role of Nurses in Prevention & Management of Bed Sore

5. • Decubitus ulcers or pressure ulcers
• It is an ulceration in the skin that is caused by
prolonged pressure on a bony or weight bearing part
of the body.
Bed Sores
DEFINITION

6. 1. Friction
2. Shear
3. Impaired Sensory Perception
4. Impaired Physical Mobility
5. Altered Level Of Consciousness
6. Fecal And Urinary Incontinence
Risk Factors
7. Malnutrition
8. Dehydration
9. Excessive Body Heat
10. Advanced Age
11.Chronic Medical Conditions-Diabetes, Cardiovascular Diseases.

7. Pathophysiology
Various risk factors act on areas of soft tissue overlying bony
prominence
Occlusion & tearing of small blood vessels
Reduced tissue perfusion
Ischemic Necrosis
Pressure sore

8. Common Sites
 Sacrum
 Elbow
 Knee
 Ankle

9. • Classification of pressure ulcers are based on the depth of tissue
destroyed.
• Based on the depth there are four grade of bedsores
 Grade I
 Grade II
 Grade III
 Grade IV
Grade / Classification Of Bedsores

10. • The most superficial, indicated by non
blanchable redness that does not subside
after pressure is relieved.
• Skin may be hotter or cooler than normal,
have an odd texture, or perhaps be painful
to the patient.
Grade 1

11. Grade 2
• A partial thickness loss of dermis presents
as a shallow open ulcer with a red-pink
wound bed without slough
• In this grade, the ulcer may be referred to
as a blister or abrasion.

12. Grade 3
• A grade III ulcer is a full-thickness tissue
loss. Subcutaneous fat may be visible; but
bone, tendon, or muscle is not exposed.
• Epidermis, dermis and subcutaneous tissues
involved.
Full-thickness Skin Loss (Fat Visible).

13. • A grade IV ulcer is the deepest,
extending into the muscle, tendon
or even bone.
• Full thickness tissue loss with
exposed bone, tendon or muscle.
Full-thickness Tissue LossGrade 4

14. Are covered with dead cells, or
eschar and wound exudate, so the
depth cannot be determined.
Unstageable Pressure Ulcer

15. Six Criteria:
Braden Scale for Predicting Pressure Ulcer Risk
 Sensory Perception
 Moisture
 Activity
 Mobility
 Nutrition
 Friction and
Shear
Sensory/
Mental
Moisture Activity Mobility Nutrition Friction/ Shear
1. Total
limited
1. Constantly
moist
1.Bedfast 1. 100%
immobile
1. Very poor 1. Frequent
sliding
2. Very
limited
2. Very moist 2. Chairfast 2. Very
limited
2. <1/2
daily
portion
2. Feeble
correction
3. Slightly
Limited
3.
Occasionally
Moist
3. Walk with
assistance
3. Slightly
limited
3. Most of
portion
3. Independent
Correction
4. No
impairment
4. Dry 4.Walk
w/out
assistance
4. Full
mobility
4. Eats
Everything

16. • Each category is rated on a scale of 1 to 4, excluding the 'friction
and shear' category which is rated on a 1-3 scale.
• A score of 23 means there is no risk for
developing a pressure ulcer while the lowest
possible score of 6 points represents the
severest risk for developing a pressure ulcer
Braden Scale for Predicting Pressure Ulcer Risk
Braden Scale Score
No Risk 19-23
Mild Risk 15-18
Moderate Risk 13-14
High Risk 10-12
Severe Risk 9 or less

17. • Cellulitis
• Bone and joint infections
• Sepsis
• Cancer
Complications of Bed Sore

18. Role Of Nurse In Prevention Of Bed Sores
• The Nurse should be continuingly assessing the client who are at
risk for pressure ulcer development .
Assess the client for:
 The predisposing factors for bed sore Development.
 Skin condition at least twice a day.
 Inspect each pressure sites.
 Evaluate level of mobility.

19.  Evaluate circulatory status (eg. Peripheral pulses, edema).
 Assess neurovascular status.
 Determine presence of incontinence
Evaluate nutritional and hydration status.
Note present health problems.
Role of Nurse in Prevention of Bed Sores

20. Interventions for a patient with Decreased sensory perception
• Assess pressure points for signs of bed sore development.
• Provide pressure-redistribution surface.
Interventions for a patient with incontinence
• Following each incontinent episode, clean area and dry
thoroughly.
• Protect skin with moisture-barrier ointment.
Interventions for a patient with Decreased activity/ mobility
• Establish individualized turning schedule.
• Change position at least once in two hours and more
frequently for the high risk individuals.
Role of Nurse in Management of Bed Sores

21. Interventions to avoid Friction and shear
• Reposition patient using draw sheet and lifting
off surface.
• Use proper positioning technique.
• Use comfort devices appropriately.
Interventions for a patient with Poor nutrition
• Provide adequate nutritional and fluid intake
• Consult dietitian for nutritional evaluation
Role of Nurse in Management of Bed Sores

22. • Evaluate the ulcer progress every 4-6 days.
• Assist the physician or surgeon in debridement
• Educate the patient and family regarding the risk factors
and prevention of bed sores.
Role of Nurse in Management of Bed Sores

23. Video Prevention of Bed Sores

24. Answer:
It is disturbing to me that so many patients in ICUs develop
pressure ulcers. I'd expect the ICU to be one of the last places a
patient would develop a pressure ulcer. Sure, these patients are at
the highest risk and have multiple problems. But I think the bigger
problem, however, is that as caregivers we are so focused on the
patient's other major organs and illnesses that we forget about the
skin. Most of the time, the patients recover, but some will have to
deal with their Stage IV pressure ulcer for months to years. It is my
opinion that the skin can also be made a priority without
compromising other organ systems.

25. Q2.What is the most common reason a patient develops a
ulcer?
A). Diabetes
B). Morbid obesity
C).Incontinence
D).Immobility
Ans. D Immobility

26. Q. 3You are assigned five patients on your nursing unit. Which
patient is at most risk for pressure ulcers ?
A). A 72 year old female weighing 82 lbs with stress
incontinence and dementia.
B). A 90 year old male with Congestive Heart Failure who
3+ pitting edema in lower extremities.
C). A 6 month old with the flu.
D). An ambulatory 88 year old with dementia who is
admitted with shingles.
Ans: - A

27. Q 4. Which of the following interventions is most
for preventing excessive heel pressure?
a. flexing the knees
b. placing a doughnut-shaped cushion under the feet
c. suspending the heels with a pillow
Correct Answer:
ANSWER: c. Use a pillow or foam cushion to lift the heels
off the mattress and eliminate the pressure. Take particular
care, however, to avoid transferring pressure to the Achilles
tendons. In addition, some support surfaces have a built-in
pressure-reducing feature specifically designed to address heel
pressure.

28. ACKNOWLEDGEMENTS
• Thank you to MS Sir ,DMS Sir and all Nursing
Officer’s for overseeing this project and providing
advisory support.
 I hope you have enjoyed this course.