Halime Aydın, Bengüsu Öroğlu, Gülcan Kar, Mustafa Öncel

PRESSURE WOUND

MD. LÜTFİ KIRDAR KARTAL EDUCATION AND RESEARCH

HOSPITALSTOMATOTHERAPY UNIT

PRESSURE WOUND

Pressure wound is lokalized tissue damage that usually occurs skin on bones and subcutaneous tissues via pressure or friction and rupture with pressure.

(NPUAP, 2007)

The most cheapest and easy way to prevent pressure wound is applications of

preventer nurse procedures.

However wounds with different grades occur because of various reasons.

It is aimed that quick recovery with good nursing and wound care.

PRESSURE WOUND

Patiens having pressure wounds are usually older than 70 age and have 8% mortality risk. (Oguz,1998)

Risk factors that induce pressure wonds without old age;Neurological diseases, Malnutrition,Chronic diseases, Physical inactivity.

CASECASE

Woman H.A., 85 age, mother of 5 children.

Blind for 40 years.

Urinar and fecal incontinence for 2-3 years.

She was hospitalized for general stiuation disorder at 29 September 2009.

It was observed that she had not any chronic disease as a result of investigations (hypertension, diabetes etc.).

HOWEVER….HOWEVER…. It was confirm that extreme malnutrition.

It was found that pressure wounds more than one.

(Sacral, torachanter and heel area)

EVALUATION RISK OF PRESSURE WOUND FORMING WITH BRADEN SCALE

EMOTIONAL SENSE

1-COMPLETELY LIMITED

2-MOSTLY LIMITED 3-SLIGHTLY LIMITED

4-NO DAMAGE

MOISTURE/WET 1-ALWAYS WET 2-FREQUENTLY WET 3-SOMETIMES WET

4-RARELY WET

ACTIVITY 1-LIVE BEDRIDDEN 2-SIT CHAIR 3-SOMETIMES WALK

4-WALK

MOTION 1-COMPLETELY INACTIVE

2-VERY LIMITED 3-SLIGHTLY LIMITED

4-NO LIMITED (ACTIVE)

NUTRITION 1-UNSUFFICIENT (CACHECTIC)

2- PARTIALLY ENOUGH

3-ENOUGH 4-VERY GOOD

FRICTION AND RUPTURE

1-PROBLEM 2- MAY BE PROBLEM 3- NO PROBLEM

*19–23: NO RİSK *15–18: RISK ON THE EDGE *13–14: MEDIUM RISK *0–12:HIGH RISK *9 AND LOWER: VERY HIGH RISK

*RISK OF PRESSURE WOUND FORMING IS 15–18 AND LOWER LOOK AT THE GUIDE OF NURSING PLAN FOR DAILY ACTIVITIES.  

PUAN

TOPLA

CASE

SACRAL AREA

PHASE III VE PHASE IV

SACRAL AREA: 22x15x5 cm

29Eylül200929Eylül2009

Torachanter 10x7x7 cm

Suspicious subcutaneous lesion

HEELSuspicion of deep tissue damage

HELL 5X5 CM PHASE II-III

NURSING PLAN

Change position of patient to reduce pressure every 2 hours,

Provide using of support materials to reduce pressure,

Clean and dry skin, Clean and creaseless sheet, Organize nurition and fluid intake, Provide adaptation of patient’s relative to nursing

plan via training.

It was gave that suitable position to the patient and changed every 2 hours.

It was provided that enough fluid intake and organized nutrition (eternal nutrition).

Skin care was done. The family was trained

for this subjects.

NURSING

Healty tissue around

the wound was cleaned with batticon.

İnternal wound was washed with normal saline.

Necrotic tissues were removed with surgical debridement.SACRAL AREA: 22x15x5 cm

WOUND CARE STEP BY STEP

AFTER 2 WEEKS 20x14x5

Infected, smelly internal wound was washed with normal saline and silver wound dressing was applied.Cavity spaces were filled with this silver woud dressing. Barrier cream was used to protect wound around.The area with rich exudate was covered with NEODERM® .

AŞAMA AŞAMA YARA BAKIMI

AFTER 6 MONTHS 13X7X2 cm

AFTER 4 MONTHS 8X4X0.5 30.01.2010

Wound was cleaned completely and there was no necrotic area.This stage, Neoderm® was applied again.

FIRST LATER

Skin was cleaned and 80-100 mL, infected, smelly and sludgy exudate was drained via opening necrotic area with surgical incision. Internal wound was washed with isotonic solution for several times and wound space was filled with silver wound dressing.

AŞAMA AŞAMA YARA BAKIMI

TORACHANTER AREASUSPICION OF DEEP TISSUE

DAMAGE

TORACHANTER AREA

Barrier cream was applied to around tissues.

Wound area with rich exudate was covered with Neoderm®.

At first, dressing was done day to day. After that, changing time was extended because of decreasing exudate.

30.9.2010 OPEN WOUND

AŞAMA AŞAMA YARA BAKIMI

AFTER OPENING TORACHANTER AREA 10x7x7 cm

AFTER 6 WEEKS

AFTER 8 WEEKS 6X4x3 cm

AFTER 4 MONTHS 3X3X3cm

AFTER 5 MONTHS 1X1.5X0.5 cm

FIRST LATER

HEEL 5X5 cm

AFTER 6 WEEKS

AFTER 4 MONTHSAFTER 2 MONTHS

NEODERM® APPLICATION

AFTER 5 MONTHS 2X2X1cm

FIRST LATER

RESULT

Pressure wounds can be treated applying well organized nursing,

And doing effective and organized wound care.

WITH HER GRANDCHILD CANSU

THANK YOU