EXTRACT
5. DESCRIPTION OF NURSING PROTOCOL
Nursing responsibility: the decubitus risk assessment, implementation of preventive measures, the
implementation of physician-ordered therapy, diagnostic tests preparation, assistance and all these
decubitus board and care documentation, documentation of care plans
Indications: all inpatient care
5.1. Proposed nursing diagnosis:
Risk of long-term tissue damage location, immobility due.
The risk of erosion due to incontinence.
The risk of pressure sores worse in the absence of a change in body position.
The risk of worsening pressure sores due to superinfection.
Pain due to pressure sores.
5.2. Material conditions:
- Antidecubitor mattress and bed
- Decubitus treatment dressings
- Anti-bedsore cream
5.3. Implementation Steps:
5.3.1. Management process:
First Risk Assessment.
Recruitment, all patients in the nursing documentation can be found in Norton scale filling, threat
determination.
Second Prevention.
The patients at risk of nursing rizikókategóriájuk the prevention grants.
Third Staging.
Skin lesions (decubitus) is detected, the identification of stage and treatment plan.
4th The stage set appropriate treatment.
5th The management of psychiatric patients.
5.3.2. Prevention guidelines (self-care skills)
First Clean, dry skin surfaces.
- Patients with bathing, washing at least once a day
- Body and skin care needs assistance necessary determination
- Patients in need of complete partial use washing several times a day
- After the bath dry skin care Clear
Second Continuous-bedding clean and dry, wrinkle-free maintenance.
- Antidecubitor mattress or bed use
- Tools for convenience
- Bedpan and urinal insertion careful execution, the application to minimize the time required
- Daily linen change
Third Active, passive position changes.
- Kétóránkénti rotate, tweak bed with passive, active or planting exercise, mobilization application (if
not medically contraindicated)
4th Long-term exposure to pressure to improve the circulation of skin.
- Improve blood circulation rubbing, massage menthol alcohol use
5th Professional, careful grooming.
- Protecting patients from injury
- Avoid immobolizáció
- Strict adherence to aseptic
- The quantity and quality of food intake to ensure
- Ensure fluid intake
5.3.3. Treatment of decubitus
The general guidelines for prevention increased compliance.
I Stage: Permanent pressure relief provision and management of erythema. (Nursing competence)
• Betadine solution Brushing and ventilation
II. Stage Conservative local therapy. The hámfosztott area's neighborhoods, in order to protect the
treated skin after epithelizing sterile wound care is performed. Medical consultation, nursing
competency.
• Betadine solution Brushing and ventilation
• Special use bandages / wound management principles to always be chosen according to /:
hydrocolloid, hydrogel impregnated gauze and film dressings
III. Stage of Treatment - dry or wet gangrene by - Conservative therapy is started. At this stage of the
infection in the wound is common, so let's start desinficiálással the treatment and protection of the
wound after wound with sterile - clarified, epithelizing - continued. (Medical consultations, nursing
competence)
• 1 Hydrogen peroxide (3%) mechanical cleaning 2 Saline solution flushing third Betadine solution
Brushing fourth Applying bandages - alginate (Kaltostat, Kliniderm) hydrogélek, hydrokolloidok
(Intrasite, Hydrosorb, Granuflex), foams (Cutinova, Mepilex), polymer dressings (Cutinova, Mepilex),
coated sheets (Grasolind, Klinitulle, Cuticerin) 5 Recording, cover joints
• comply with the dressing to the wound and surrounding skin condition, the degree of ulceration,
exudate amount of the exclusion of infection. The bandages according to the manufacturer's
instructions must be used and replaced.
• The doctor has prescribed medication (local and general) and proper use of diagnostic tests,
treatments, topical preparation, execution - that of professional skills.
• Necrosis excision. (Medical competence)
IV. Stage Necrectomia, surgery, plastic surgery. (Medical competence)
5.4. Documentation:
- Nursing documentation: care plans and Norton scale for risk stratification, treatment of decubitus
instruction sheet decursus record a comment
- Decubitus control panel: Determination of decubitus stage, treatment undertaken Record
Norton scale
General
status
good
Mental
status
vigilant
satisfactory
apathetic
bad
disturbed
condition
very
bad
insensible
condition
Active
Mobility
Inkontinence
Point value
ambulatory
perfect
no
walking with the
somewhat hindered opportune
help of
4 point
aided
greatly hindered
often, urin
2 pont
confined to bed
immobile
full of feces and
1 pont
urine
3 pont