Set of activities performed by the nurse on pressure ulcers presented by the patient to promote tissue regeneration until healing or improvement.
Objective:
To restore the integrity of the patient’s skin.
Equipment:
– Dressing material: scalpel handle, Kocher forceps, dissecting forceps with or without teeth.
– Sterile drapes.
Material:
– Sterile dressings.
– Sterile compresses.
– Sterile gauze.
– Sterile gloves.
– Non-sterile gloves.
– Anti-allergic plaster.
– No. 15-21 scalpel blade.
– Debridants.
– Dressings.
– Physiological saline 0.9%.
– Syringe 20cc.
– IV needle.
– Nursing records.
Procedure:
– Prepare the dressing trolley.
– Preserve the patient’s privacy.
– Inform the patient.
– Ask the patient and family to cooperate.
– Place the patient in a suitable position to cure the ulcer.
– Assess the ulcer: location, stage, size (length, width and depth), description of the appearance, signs of infection or pain.
– Assess ulcer-related pain or its treatment as well as the need to apply any analgesic, if appropriate.
Basic rules for all pressure ulcers:
Apply the prevention procedure.
Perform hand washing.
Put on sterile gloves.
Use sterile dressing kit.
Clean the wound with physiological saline solution.
Dry the wound without dragging.
Assess injury and choose appropriate treatment.
– Heal according to wet healing technique.
– Apply the appropriate treatment according to the stage of the ulcer. The GNEAUPP proposes the classification into stages according to the degree of tissue involvement.
Stage I: erythematous phase (non-palpable skin erythema on intact skin).
– Possible therapeutic alternatives: Apply hyperoxygenated fatty acids (three times a day). Do not massage reddened areas or over bony prominences. Polyurethane sheet or thin film, polyurethane foam dressings or extra thin hydrocolloid, hydrogel plate.
– Place protective dressing.
Stage II: scoriative phase (superficial ulcer involving epidermis, dermis or both with moderate exudate).
Place absorbent dressing:
– Polyurethane foam and hydrocolloid paste or gel in extra-fine or normal dressing ulcers with little to moderate exudate.
– Hydrocellular dressings, calcium alginate, hydrocolloids combined with calcium alginate or fiber, hydrogels in amorphous structure and in dressings with moderate to profuse exudate.
– If there is a cavity: also hydrocolloid paste.
– If there is necrotic tissue: debride.
Stage III and IV: scoriatic/necrotic phase (ulcer involving subcutaneous tissue, muscle and sometimes bone and tendons).
– Place absorbent protective dressing by filling 3/4 of the cavity with specific products.
– Remove the filling material from other dressings.
– If there is a lot of exudate, in addition to the above, place a calcium alginate hydrofiber dressing.
– If there is necrotic tissue, debride.
– Use sterile non-transparent dressing.
– Do not use occlusive dressing if the ulcer involvement is bone and tendon.
Infected ulcers:
– Do not use occlusive dressing.
– Intensify cleaning and debridement, performing dressings every 12-24 hours.
– Use hydrogels, hydrofibers or calcium alginate and use as secondary dressing, gauze, hydrofiber dressings, calcium alginate or charcoal/silver.
– If there is no improvement, take a culture sample from the wound and inform the physician in case systemic antibiotherapy is necessary.
Ulcer with necrotic tissue: debridement treatment.
Types of debridement:
– Surgical: Technique and sterile material. Requires dexterity, is quick and can be painful. Cutting by planes and in different sessions, always starting from the center of the lesion.
– Enzymatic: it is slower, painless and can even macerate healthy tissue. Enzymatic ointment (collagenase) is applied for 24-48 hours with gauze moistened with saline. To improve efficacy make incisions on the scab and apply the ointment or hydrogel with a syringe and needle.
– Autolytic: hydrogel dressings that produce moist healing conditions. These products soften and separate necrosis and dry plaques by absorbing them into the gelatinous structure. It is slow, selective and does not damage granulation tissue.
– Enzymatic and autolytic debridement can be combined with surgical debridement.
Technique for application of commercial dressings such as hydrocolloids, hydrogels, etc.
– Apply directly on the ulcer leaving a margin of 2.5-4 cm.
– The frequency of dressing change will be determined by the level of exudate.
– Do not remove prematurely because it destroys the granulation tissue that is forming.
– Reinforce the edges with adhesive tape that does not damage the perilesional skin.
– Date dressing application.
– Collect the material.
– Remove gloves.
– Perform hand washing.
– Note in nursing records: record the care given.
Observations:
– In patients with several ulcers always start with the least contaminated.
– The change and frequency of dressings will depend on the degree of exudate and the state of the dressing.
– Do not use any type of antiseptic as it destroys the granulation tissue.
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