Info

aged pads

membrane; Tegaderm

that are permeable to oxygen and water vapor; appropriate for partial-thickness wounds; useful as secondary dressings for wounds treated with hydrocolloids or alginates

Independent

The most important nursing intervention is prevention. Identify patients who are at risk by using assessment tools such as the Braden scale or the Norton scale, which determine the sensory and physiological factors that increase the incidence of pressure ulcers. The high-risk patient needs turning and proper positioning at least every 2 hours. Pressure-relieving devices, such as sili-cone-filled pads and foam mattresses, may be helpful. Dynamic devices include specialty beds (low-air-loss, air-fluidized, and air cushions). Airflow pressure mattresses are also useful preventive strategies.

Keep the patient's skin dry. Patients who are incontinent of feces and urine should be cleaned as soon as possible to prevent skin irritation. When soiling of the skin cannot be controlled, use absorbent underpads and topical agents that act as moisture barriers. Avoid the use of hot water, and use a mild cleansing agent to minimize dryness and irritation in high-risk patients. Treat dry skin with moisturizers, but use care in massaging bony prominences as this may impede capillary blood flow and increase the risk of deep tissue injury. Lift high-risk patients up in bed instead of pulling them, which increases the risk of shearing and friction forces on the skin's surfaces. To prevent the patient from sliding down in bed, do not elevate the patient's head more than 20 degrees unless this angle is contraindicated because of other medical problems or treatment modalities. Keep linens dry and wrinkle-free. When skin breakdown occurs, apply appropriate dressings using clean technique or, in cases which infection is present, sterile technique.

Teach the caregiver preventive strategies, and determine if the patient's situation is in jeopardy because of inadequate care. Note that the caregiver may have feelings of guilt because of the failure to prevent complications of immobility; the caregiver may need support rather than teaching, depending on the situation.

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