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Reposition - Pressure Ulcers Video

This video illustrates a simple way different postural changes may be made to a bedridden patient to prevent ulcer development pressure.

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are also called bed sores and ulcers or bed sores. The pressure ulcer (PU) is the injury of ischemic origin located in the skin and underlying tissues, with loss of cutaneous substance produced by prolonged pressure or friction between two flat hard.

The tissues receive oxygen and nutrients, as well as remove metabolic wastes through the blood. Any factor that interferes with, affects cellular metabolism and thus the function or cellular life. Pressure affects this process, to reduce or block blood flow, tissue that gives rise to ischemia and subsequent necrosis. Usually the two planes drives that are compressed are the bony prominences of the patient and any other hard surface, like a bed or chair.

DRIVERS

ulcers are caused by prolonged pressure and constant, soft tissue between a bony prominence and a hard level. This causes ischemia of the vascular membrane, leading to vasodilation of the area (as evidenced by a reddish appearance), extravasation of fluids or cellular infiltration.

If the pressure does not decrease, there is a severe local ischemia in the underlying tissues, venous thrombosis and degenerative changes, leading to necrosis and ulceration. This process can continue and reach deeper levels with destruction of muscle, fascia, bones, blood vessels and nerves.

Impaired skin integrity resulting in this type of ulcers, is primarily due to the pressure but Other factors that contribute to the development of PU.

1. Pressure: is the force that acts perpendicular to the skin as a result of gravity, causing a crush hard tissue between two planes, one from the patient and one outside it.

The appearance of the UPP will depend not only on the degree of pressure applied on soft tissues, but the time that remains, so a little pressure exerted on tissue for two hours, can give rise to lesions with a frequency greater than a pressure of more sustained intensity for less time.

2. Forces Shearing: are pressures on the skin when the patient is moved or repositioned in bed pulling, or if allowed to slide in it. In the presence of these forces, the skin and subcutaneous layers stick to the surface of the bed, whereas strata muscle moving in the direction of motion to submit the body.

3. Friction: is a skin lesion that looks like abrasion. The friction results from friction between two surfaces. Body surfaces with more friction are the elbows and heels.

4. Humidity: When the skin is damp, there is more risk of developing ulcers. Moisture reduces the skin resistance to other physical factors such as pressure or shear forces. Moisture can come from: a wound drainage, perspiration, oxygen humidification system, vomiting and incontinence. The prolonged exposure to moisture increases the risk of PU.

5. Poor nutrition: increases the risk of pressure ulcers. Because patients with poor nutrition have reduced muscle atrophy and subcutaneous tissue, therefore the pressure effects are magnified. The risk that triggers poor nutrition is related to:

• Edema: This related to fluid and electrolyte imbalance, and that triggers a migration of extracellular fluid into the tissues producing the edema. Blood flow to the edematous tissue is reduced.
• Anemia: The presence of anemia increases the risk of pressure ulcers because the lower values \u200b\u200bof Hb, causing a decrease in the amount of oxygen in blood and consequently to the tissues.

Other factors related to sex, age, underlying disease and conditions of wounds. Other conditions that predispose the UPP:

• Infection: The patient with infection usually have fever, altered metabolism, causing a hypoxic tissue more susceptible to injury. In addition, a febrile episode, produces diaphoresis contributing to excessive moisture.
• Impaired peripheral circulation: By reducing the peripheral circulation, the tissue becomes more susceptible to hypoxic and ischemic injuries. This occurs in patients with vascular problems, shock or drug vasopressor.
• Obesity: adipose tissue vascularization is low, so the underlying fatty tissues and are more susceptible to ischemic damage.
• Cachexia: The cachectic patient has lost the fat necessary to protect bony prominences of the pressure.

AREAS WHERE FREQUENT OCCURRENCE OF PRESSURE ULCERS

The areas at risk of occurrence of pressure ulcers varies with the position taken by the patient, but the most common:

- Sacrococcygeal Zone
- Hip
- Greater trochanter
- Elbow
- Heel
- Scapula
- Patella (Knee)
- Malleolus (ankle prominence)
- Occipital region (behind the head)
- Oreja

may also occur between the skin folds in obese people. Appearing then: under the breasts, buttocks under, among others.

STAGING OF UPP UPP

The clinical manifestations vary according to their gravity. According to established staging can determine the severity of the UPP, and its subsequent treatment.

• Stage I:

Erythema skin intact skin does not blanch. In dark skin, may have shades of red, blue or purple. Changes may include:
- Skin temperature (hot or cold)
- Consistency of the tissue (edema, induration)
- such as pain or burning sensations.

• Stage II:

partial thickness loss of skin involving epidermis and / or dermis. Superficial ulcer-like abrasion, blister or shallow crater.

• Stage III:

total loss of skin thickness. Involves them injury or necrosis of subcutaneous tissue. Can appear or tunneled caverns. You can extend downwards.

• Stage IV:

lesion with extensive destruction, tissue necrosis or damage to the muscle, bone or supporting structure (tendon, etc.).. May appear caverns tunneled or paths winding. It is important to the removal of necrotic tissue to identify the stage of the ulcer.

SCALE BRADEN FOR RISK ASSESSMENT OF UPP

On this scale should be rated the patient for each of the six subscales. The maximum score (23 pts.) Is indicative of little or no risk. A score less than or equal to 16 pts. indicates the existence of risk and a score less than or equal to 9 pts. is indicative of high risk.

Humidity constantly wet Very wet In Mobility Completely immobile

POINTS	1	2	3	4
Sensory Perception	Fully	limited Very limited	Slightly limited	not altered
			Occasionally wet wet	rarely
Activity	In bed		chair occasionally Walk Walk	often
		Very limited	Slightly limited	Unlimited
Nutrition	Very poor	probably inadequate		Adequate Excellent
and sliding friction	is a problem	is a potential problem	No apparent problem	-

estimated that the highest percentage of pressure ulcers are potentially preventable, so that their appearance is directly related to the quality of care provided by nursing professionals.

TREATMENT OF UPP

treatment of pressure ulcers depends on the stage in which it is the patient. Good nutrition is critical patient, being recommended total caloric intake of at least 35% calories / kg / day with a protein intake of 1.25 to 1.50 g / kg / day.

The successful treatment of pressure ulcers includes proper cleaning of the wound in each cure, prevention, diagnosis and treatment of infection. Besides choosing a suitable dressing.

UPP In Stage I will ease the pressure on the affected area is administered hyper-oxygenated fatty acids and proceed to the implementation of local measures to achieve the relief of pressure by:

- Dressings to reduce friction.
- Allow observation the affected area.
- Avoid damage healthy skin.
- Use of topical products for skin care.

UPP In Stage II, III and IV, you have to consider:

- debridement of necrotic tissue.
- Clean the wound.
- Prevention and treatment of infection.

GENERAL NURSING INTEVENCIONES

Early detection of patients at high risk and the risk factors contributing to the prevention of pressure ulcers by the nursing professional. General interventions include:

risk rating: By using specific scales (Braden, Norton, etc.). Hygiene

skin, skin care and topical treatment:
One of the key objectives is to maintain the patient's skin clean and dry. In this first line of action, the nursing professional should assess the patient's skin constantly. Activities are summarized:

- Review daily.
- Be aware of bony prominences.
- Identify areas at risk of moisture.
- Take into consideration the presence of dry, maceration, erythema.
- Use soap.
- Apply moisturizers in risky patients (Elderly)
- Avoid using irritants
- Consider the use of dressings and soft surfaces in areas of pressure.

Moisture Management:
When the patient's skin is exposed to bodily fluids such as urine, feces, or wound exudate should be wiped off the area and apply an alcohol-free skin barrier, making skin protection against excess moisture and toxins from the body fluids. Search
moisture protection measures in patients with incontinence urine.

Pressure Management and Repositioning:
repositioning actions are designed to reduce pressure and shear forces acting on the skin. It should take the following general measures:

- Encouraging the mobilization.
- Reposition every 2 or 3 hours to patients in bed, and every hour if the patient is seated.
- The lateral should not exceed 30 degrees.
- Avoid direct pressure points.

The position of disabled patients should be changed depending on the level of activity, the ability to appreciate and daily routine paciente.Es must also teach the patient to move the body weight every 15 min. In addition to stand the pressure zones or soft cushions of air. Once
repositioning the patient, the nursing professional must continuously assessing the skin. It is worth mentioning that pressure redness NEVER be massaged.

Using special support surface
The use of such areas shall be determined by:

1. low-risk patients: static surfaces (mattresses or alternating air cushions, silicone or foam)
2. Medium-risk patients: dynamic surface (mattresses or pads alternating with air, lateral positioning, bariatric beds).
3. High-risk patients: dynamic surface .

have designed a wide variety of therapeutic beds and mattresses designed to reduce the risks of immobility warrants. While these complement your overall goal with good nursing care. No device that by itself eliminate the effects of pressure on the skin.

be taught to patients and their families, way to use these beds and mattresses and the reason for use. If the application is successful, the risk of pressure ulcers is decreased in patients at high risk.

nutritious and adequate oxygenation State:
Maintaining adequate protein intake and adequate levels of hemoglobin is an important aspect in the treatment of pressure ulcers.

Healing of pressure ulcers:
The constant monitoring and recovery (cleaning) of the ulcers formed contributes to improving the same, depending on the stage.

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starts to install the base station of public bike system, Valenbisi

these photos I've taken this afternoon in the Avenida del Puerto, in front of Telefónica:

The pole rental management


poles fixing bikes in the installation process

I sincerely hope that this encourages the use of the bike in Valencia, a city very conducive for it, but its network of bike paths going to need a serious improvement: very narrow lane (when passing two bikes in opposite directions, not play for very little), areas of pavement made with concrete rails smoothed to polishing (wet ice rink are true, I've seen a couple of serious accidents, love of many mild, try to stop in these areas).

more about Valenbisi in www.valenbisi.es