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EDUCATION.

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is very important to give an education to patients suffering from pressure ulcers, their relatives or persons responsible for their care. This education is given a series of guidelines on how to continue the treatment, and care, you should do .....



Therefore it is important: Teaching to keep the skin dry and clean (give specific instructions agree with the cause). Teach how to change instantly
wet diapers.
Explain the need to increase protein intake during
healing of tissues.
Explain how the position is held anatomically correct:
provide clear details, so you get the right position.
teach how to make position changes:
The change in body position prevents congestion from respiratory secretions, sputum
facilitates, promotes circulation, provides welfare
to avoid prolonged pressure on certain body areas, reducing fatigue and
prevent contractures.
The bedridden person must move from one position to another: 1 .-
supine position :
Keep your head, face up, in a neutral position and rec ta
so that is in alignment with the rest of the body;
support the knees slightly flexed position to prevent hyperextension
(extremities abducted 30 degrees), elbows straight and hands
open.
be protected supine:
- Occipital
-
shoulder blades - Elbows
- Sacrum and coccyx
- Heels
2 .- prone position.
Place (is) on the abdomen with the face turned to one side over a cushion, the arms flexed
surrounding the pad, palms turned downward and the feet extended
. Support the ankles and shins to prevent
plantar flexion of the feet.
be protected in the prone position:
- Front
-
Eyes - Ears
- Cheek
- Push
- Male genitalia
- Kneeling
- Finger
3 .- lateral decubitus position:
maintain alignment with leg on the side on which desca nsa
body stretched and flexed contrary, the upper limbs flexed.
thigh support pillow and arm to prevent
internal rotation of the hip and shoulder.
in left or right lateral decubitus special attention to:
- Ears
- Shoulders
- Ribs
- iliac crests
- Trochanters
-
Twins - Warm
- malleolar
4 .- Seated: Sit
(him) with his back comfortably against a firm surface.
Place a pillow under each arm, and a roll in the cervical region
. Seated
, monitor and protect:
-
shoulder blades - Holy

- ischial tuberosity.

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MATERIAL / EQUIPMENT

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The material used for the care of pressure ulcers is very diverse. You need sheets, graphs .... tools such as forceps, scalpels, gloves ......


Material:
direct observation, interview.
Rating Sheet / Record of pressure ulcers. Sterile gloves

neutral soaps or cleaning agents with potentially curative
moisturizing and nourishing products: almond oil.
Vaseline ointment
absorbents, salvacamas, etc. extra thin hydrocolloid dressing

cushions, pillows, mattresses antiescaras, local protections, pads, etc.
.
cloths.
sterile gloves.
towels and gauze pads. Set
cures: toothed dissecting forceps, scalpel handles, scalpel blade
.
saline.
bandages, pads, ...
enzymatic debridement.
lidocaine 2% gel-based dressings
wet cure:
Hydrocolloids / hidrorreguladores, plaque, granules, paste or
hydrofiber. Alginates. Hydrogels in amorphous structure on board.
Polyurethanes. Dressings
Hidropoliméricos.
material needed for growing collection.


Team:

Nurse / o.
Nursing Assistant.
Celador.

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GENERAL CARE IN THE TREATMENT OF UP.

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Prevention of new UP: Have higher risk of developing new UP those who already have or had UP. Place greater emphasis on prophylaxis in these patients. * Support Nutrition: Good nutrition support promotes healing and may prevent the development of new lesions. The nutritional needs of a person with UP are increased and the diet should ensure a minimum:
calories: 30-35 kcal per kg. body weight per day.
Proteins: 1.25-1.5 g / kg. weight day. In cases of hypoproteinemia may need up to 2 g / kg.



Minerals: Zinc, iron and copper.
Vitamins: C, A and B. Support
water: 30 cc of water per day per kg. weight. If this is not covered with the usual diet supplements hyperproteic use of oral enteral nutrition to prevent deficiency states and placing the patient in a positive nitrogen balance.
* Support emotions: There is a decrease in functional ability that affects both the individual and the family. Keep in mind the psychological support and education when developing the plan of care and monitoring.
ULCER CARE : 1 .- Basic Plan 1 - Debridement of devitalized tissue. 2 - Clean the wound. 3 - prevention and treatment of infection. 4 - Choosing a dressing. In any case, the strategy of care will depend on the overall situation of the patient.

2 .- debridement. The wet tissue and devitalized promotes the proliferation of pathogenic organisms and interferes with the healing process. The method of debridement chosen depending on the patient's overall situation and the characteristics of the tissue to debride. Different methods that are exposed can be combined for best results.
· Surgical debridement is considered the fastest way to eliminate areas of dry scars attached to deeper levels, moist areas of necrotic tissue or areas of devitalized tissue in extensive ulcers. Also be used when there is an urgent need desbridaje (eg progressive cellulitis or sepsis). It is a cruel method that requires skill, technical skills and appropriate material. Small wounds can be made at the bedside, but will be extended in the operating room or in a suitable room. Be carried by planes and several sessions (except the radical desbridaje surgery) starting at the center and seeking to achieve early release of devitalized tissue on one side of the lesion. When debriding Stage IV ulcers should be considered in surgical bone biopsy to rule out underlying osteomyelitis.
To avoid pain during these operations it is advisable to use a topical analgesic (lidocaine gel 2%). If there is bleeding control can be made by direct compression, hemostatic dressings, etc.. If the bleeding will not yield to resort to suture the bleeding vessel, once controlled you should use a dry dressing for 8 to 24 hours and subsequently exchanged for a wet.
· Chemical or enzymatic debridement: Rate this zero tolerance approach when surgical debridement and no signs of infection. There are proteolytic and fibrinolytic products, such as collagenase. These enzymes hydrolyze the matrix surface and soften necrotic eschar desbridaje prior to surgery. It is recommended to protect the fabric periulceroso with a paste of zinc or silicon and increase the humidity of the wound to enhance their action. This method is ineffective to remove a hardened scar tissue or large amounts in deep beds, in these cases would require several applications which also costs more expensive and more tissue damage adyacente.
· Desbridamiento autolítico: Se realiza mediante el uso de apósitos sintéticos concebidos en el principio de cura húmeda. Al aplicarlos sobre la herida permiten al tejido desvitalizado autodigerirse por enzimas endógenos. Es un método más selectivo y atraumático. No requiere habilidades clínicas y es bien aceptado. Su acción es más lenta en el tiempo y no deben emplearse si la herida está infectada. Se emplea en general cualquier apósito capaz de producir condiciones de cura húmeda y de manera más específica los hidrogeles de estructura amorfa (geles). Estos geles se consideran una opción de desbridamiento en el caso de heridas con tejido esfacelado, ya que por su acción Moisturizing facilitate the removal of nonviable tissue
· mechanical debridement: This technique is not selective and traumatic. Is performed by mechanical abrasion by forces of friction (rubbing), use of dextranomer, irrigation pressure or use of wet gauze type dressing with 0.9% sodium chloride at dry 6-8 hours past adhere to necrotic tissue, but also healthy, that starts with its withdrawal. At present techniques obsolete.
3 .- debridement. Clean lesions at baseline and every cure. Used as standard saline using an atraumatic technique using a low mechanical strength and less coarse materials both in cleaning and drying. Using an effective cleaning pressure to facilitate drag without causing trauma to the bottom of the wound. The effective cleaning pressure ulcer between 1 and 4 kg/cm2. To achieve a pressure of 2 kg/cm2 over the wound, it is recommended to use 35 ml syringe with a needle or catheter of 0.9 mm.
not use local antiseptics (povidone-iodine, chlorhexidine, hydrogen peroxide, acetic acid, hypochlorite solution) or skin cleansers. All products are cytotoxic to the new tissue and its use can sometimes cause systemic problems due its absorption. Other agents that slow the healing is topical. 4 .- Prevention and Care infection. The UP stage III and IV are colonized by bacteria. In most cases cleaning and debridement appropriate bacterial colonization prevents the progression to clinical infection. The diagnosis of infection associated with UP should be primarily clinical. The classic symptoms include inflammation (erythema, edema, heat), pain, odor, and purulent discharge. Infection of a UP may be influenced by factors specific to the patient (nutritional deficiency, obesity, drugs, immunosuppressants, cytotoxic- comorbidities, advanced age, incontinence) and others related to the injury (stage, presence of necrotic tissue and sloughing, tunneled, sensory disturbances, poor circulation in the area). If there
signs of infection, most only have to step up cleaning and debridement. We must insist on the general rules of asepsis, sterile gloves, washing hands, and begin healing the UP less polluted. If after 2-4 weeks of treatment persist signs of local infection or UP not progressing well, should be treated with topical assay against Gram-negative, Gram positive and anaerobic bacteria, which are microorganisms that infect the UP more often. The most commonly used topical antibiotics in these situations is the sulfadizaina silver and fusidic acid. Should be monitored for allergic sensitization or other adverse reactions to these drugs. If after a maximum of two weeks of treatment with topical antibiotics, the lesion progresses or persists bleeding should be performed quantitative cultures of bacteria from soft tissue and osteomyelitis rule. If there is suspicion or evidence of cellulitis, osteomyelitis, or bacteremia, the patient is susceptible of urgent medical attention. Exudates
crops not used to diagnose infection, and that all PUs are colonized on the surface. Cultures should be performed by percutaneous needle aspiration or tissue fragments obtained by biopsy of UP.
Healing may be impaired by bacteria levels above 105 organisms per gram of tissue. Treatment with systemic antibiotics according to antibiogram will.
Empirical therapy pending susceptibility testing be performed against the most common organisms: S. aureus, Streptococcus sp, P. mirabilis, E. Colli, P. aeruginosa, Klebsiella sp, and anaerobes such as B. fragilis.
Although the diagnosis of osteomyelitis is the gold standard bone biopsy, this invasive technique is not always appropriate in patients with UP. 5 .-
Election dressing. To promote healing of the UP dressings should be used to keep the bottom of the ulcer continuously wet. The ideal dressing should be: biocompatible, which protects the wound, keep the bed moist and the surrounding skin dry, allowing the removal and control of exudate and necrotic tissue, leaving the least amount of waste.
gauze dressings do not meet most of these features. Gauze dressings that stick to the wound, drying should only be used for debridement and we must differentiate dressings saline gauze permanent fund that keep the wound moist.
The selection of wet dressings depends on: location of the lesion, stage and severity, amount of exudate, tunneled perilesional skin condition, signs of infection, performance status, level of care and resources, cost-effectiveness and facilities self-care.
To prevent abscess formation should be removed partially filling the dead space between half and three quarters of the cavities and tunnels with wet curing products that will prevent "false closure."
The frequency of dressing changes will depend on both the product characteristics of the wound. Dressings are applied near the anus are difficult to keep intact for what to monitor and adjust stretching the edges "framed" with tape.
· wet dressings: There is a growing number of these products on the market. For the clinician it is important to familiarize yourself with the different classes and know and use but a limited number of them
Overall occlusive dressings should be avoided if clinical infection. If used must be controlled prior infection or increase the frequency of dressing changes. 6 .-
adjuvant treatment. Electrical stimulation is the only additional therapy may be recommended. UP may be raised in stage III and IV who have not responded to conventional treatment. Be made only with adequate equipment and qualified staff will follow a protocol, the efficacy and safety has been demonstrated in controlled trials. 7 .-
surgical repair. Considered in patients with clean UP stage III or IV do not respond to proper care. Assess potential candidates medically stable, adequate nutritional status, which can tolerate blood loss surgery and postoperative immobility.
additional considerations to keep in mind: quality of life patient preferences, treatment goals, risks of recurrence and expected outcomes of rehabilitation. 8 .-
Palliative Care and UP. A patient is terminal is not "surrender." In this case the action shall be addressed to: Do \u200b\u200bnot blame the environment. Avoids aggressive techniques. • Maintain the wound clean and protected to avoid infection. • Use of dressings to allow priests frequency distance. Avoids the pain and bad smell (odor absorbing dressings). • In agony situation assess the need for repositioning.
9 .- Evaluation and improvement of the quality . The evaluation process is essential to improve the effectiveness of the procedures. It should establish a systematic quality improvement, with continuous interdisciplinary approach that can be monitored, evaluated and modified. Periodic surveys should take incidence and prevalence in order to make a measurement of the results of the protocols. Data should be collected preferably concurrently rather than retrospectively.

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TREATMENT OF PRESSURE ULCERS.

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Pressure ulcers are a major challenge facing healthcare professionals in their practice. The treatment of patients with ulcers pressure should include the following elements:
- Consider the patient as a whole - Make a special emphasis on prevention. - To achieve maximum involvement of the patient and his family in the planning and implementation of care - Develop clinical practice guidelines on pressure ulcers at the local level with the involvement of community care, specialized care and health and social care - Configure framework of evidence-based clinical practice - make decisions based on the dimension of cost / benefit - Constantly evaluate clinical practice and incorporate professional activities research.


ASSESSMENT: This is the starting point and basis of treatment planning and evaluation of results. A proper assessment is also essential in communication between caregivers. The assessment should be made in the context of patient health, both physical and psychosocial. Initial assessment
· : complete medical history and physical examination with particular attention to: Risk factors (immobility, incontinence, nutrition, level of consciousness ...); diseases interfere with the healing of the UP (vascular disorders, respiratory , metabolic, immunologic, neoplasms, psychosis, depression ...); elderly snuff, alcohol, hygiene, drugs. Complications (pain, anemia, infection ...)
- Nutritional assessment: the goal is to ensure adequate nutrients to promote healing. Using a simple method of screening for nutritional deficiencies (calories, protein, serum albumin, minerals, vitamins, water intake. Reassess periodically.
- Rating psicosocial.Valorar capacity, ability and motivation of the patient to participate in their treatment program. This information is critical to the care plan is adequate to establish the individual
· rating environment: The objective is to create an environment conducive to compliance with the treatment plan. Identify the primary caregiver. Assess skills, availability, knowledge and resources around the caregiver (family, informal caregivers).
· rating injury: should be described by unified parameters to facilitate communication between professionals and to check the progress. It is very important to the assessment and registration of the same week. Whenever there is deterioration of the patient or the wound should be reassessed treatment plan. The assessment should include:
- Location of the injury. - Staging. - Dimensions. - Existence of fistula formation or excavations. - Type of tissue present in the bed: necrotic, slough, granulation. - State of surrounding skin: full, torn, macerated, eczematization, cellulite ... - Discharge of UP: poor, profuse, purulent, hemorrhagic, serous. - Pain. - Clinical signs of local infection: purulent discharge, odor, swollen edges, fever. - Seniority. - Course-evolution
PRESSURE RELIEF ON THE TISSUES. The objective is to improve the viability of soft tissue and promote healing of the injury by placing UP optimal conditions for healing (forces of pressure, temperature and humidity). Each performance will be directed to reduce pressure, friction and shear, which may be obtained by positioning techniques (in bed or sitting) and an appropriate choice of surfaces.
· positioning techniques: Sitting - If the UP is located on the seating surface, to avoid this position. Exceptionally, helping to support surfaces to ensure the pressure relief be allowed for limited periods.
If there is no injury on the seating surface: changes in position schedules, facilitating the exchange for support of their weight every 15 minutes with postural change or conducting drives. Bedridden
: - Do not put on the UP. - If it is not possible because the patient's condition or the number of injuries: increasing the frequency of changes. . Can be useful surfaces. In both: - Never use float type devices. - Always make a written individualized program. - Involve the caregiver. In high-risk patients make more frequent changes.
· Support Surfaces: Consider the choice the patient's clinical condition, the characteristics of the institution or level of care and characteristics of the surface. His choice is based on the ability to counteract the elements and forces that may increase the risk of injury or increase them, as well as its ease of use, maintenance, cost, comfort, and patient preferences. - Your job is important in the prevention and adjuvant treatment. Never replace repositioning.
- If a PU does not cure the whole plan should be reassessed before replacing the surface. Can act at two levels: - Areas to reduce pressure: the values \u200b\u200bof pressure reduction are not necessarily below that prevent capillary closure. - Pressure-relieving surfaces: the values \u200b\u200bof pressure reduction in the soft tissues are below capillary occlusion pressure, also eliminates friction and shear.
Guidelines for the use of support surfaces: Surfaces Using reduction or pressure relief patient's specific needs.
- Using static area if the individual changes can take place.
- Using dynamic surface if you can not bear them.
- It is recommended that those responsible for resource management were available for some of these areas, the benefits to be derived. Its allocation should depend on social circumstances and the patient's risk, so we suggest the systematic use of risk assessment scale. Requirements for support surfaces: - To be effective in reducing or relieving pressure. - To increase the bearing surface - To facilitate the evaporation of moisture. - What causes low heat to the patient. - To reduce shear forces. - Have good value for money. - What is management and maintenance. - It is compatible with needs of cardio-pulmonary resuscitation if required.

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NURSING PLAN OF ACTION.

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Precautions: The prevention is one of the basic nursing care, this care is especially relevant in patients admitted to hospital and intensive care units, as given its characteristics many of them are likely to develop pressure ulcers. Assess the risk of developing pressure ulcers at the time of hospital admission, and apply the scale of Braden 48 - 72 hours after hospitalization and periodically monitor the patient's clinical condition.


Any patient in hospital should have a systematic evaluation of the skin at least once every six hours, making emphasis on bony prominences, pressure inspecting each site to assess the status and integrity of the skin, looking for early signs of lesion, erythema, temperature changes, cracks, dryness or humidity. It is important to consider the educational objectives according to specific patient needs, according to a schedule for position changes have a special mattress, cushions, bumpers, etc., use proper body alignment techniques and the use of special support surfaces, to reduce pressure on likely reducing the bony ace! the risk of pressure sores and helping the rapid healing of existing ulcers. Given the Braden Scale, setting out the following preventive measures: Sensory Perception: This refers to the ability to respond appropriately to the discomfort that comes the pressure of the skin. Completely limited and hardly limited to: changes position every 2 hours using proper posture and functional. Lubricating the skin with each change of position, (alcohol-free creams, moisturizers, lanolin, forming protective film and is easily absorbed). Avoid massage over bony prominences. Using anti-bedsore mattress. Heel and elbow protectors. Use of other protection and support, such as pillows, foam wedges, pads, rolls. Place sheet of movement from the axillary region, to the region glútea.Colocar transparent dressings stage I and II or hydrocolloids superficial.Evitar ulceration of the skin moisture, especially in anatomical folds, armpits, breasts, English. Use devices that raise the heels to avoid pressure. Keep postural alignment, distributing the weight through support and protection devices.

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NURSING MANAGEMENT GUIDE TO PREVENT PRESSURE ULCERS.

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Humidity: Extent to which a person's skin is exposed to humedad.Después each deposition and removal, wash the perineal area with soap and water. Change the diaper as necesidad.Colocar sunscreen containing zinc to prevent dermatitis contacto.En men put condoms connected to a collector type cistofló, taking into account that is the right size, do not change it as needed tourniquet and do not use tape to hold the condom, to assess the presence of discharge from meatus, color and integrity of glande.Evite hot water use and exposure to cold.


Activity: Assist patient in ambulation. Provide walker, crutches and teaching staff and verifying its proper use. Use bath chair, chair and stool elimination seat neurological wheelchair. Lifting the patient out of bed and move it to the chair using the crane. Active and passive exercises for upper and lower limbs as Service indication of Physical Medicine and Rehabilitation. Verify compliance with the individualized physical therapy program. Encourage ambulation in and out of the room where patients can. Mobility: The ability of the person to change and control body positions. Place sheet of movement from the axillary region, to the buttocks. Schedule changes position every 2 hours, keep the card status change in the room. Lubricating the skin at each change of position, (alcohol-free creams, moisturizers, lanolin, forming protective film and is easily absorbed). Rating la piel en cada cambia de posición. Movilizar el paciente en la cama utilizando el arco balcánico a trapecio. Evitar caídas accidentales manteniendo las barandas de la cama elevadas. Mantener tanto la sábana de la cama coma la sábana de movimiento sin pliegues. Evitar el deslizamiento del paciente en la cama (levantar la cabecera 300 y los pies 200 Colocar al paciente en posición lateral con 30° de inclinación, con el fin de evitar la regurgitación y bronco- aspiración. Nutrición : Realizar control de ingesta diario y de líquidos. Sugerir la realización de una valoración nutricional. Controlar peso diario par medio de la pesa metabólica. Asistencia en la dieta. Administración de nutrición enteral o parenteral. Fricción y descamación : Roce continúo de la piel del paciente con elementos externos (ropa, sábanas, etc.) secundaros a la disminución en la actividad y en la movilidad. Aplicar las medidas preventivas recomendadas según el tipo de riesgo de cada paciente y de la guía de manejo.

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PREVENTION OF RISK FACTORS.

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El mejor tratamiento para las ulceras par presión es la PREVENCIÓN. La identificación y debida clasificación del riesgo permite definir las estrategias de manera integral de enfermería. Existen numerosas escalas para medir y clasificar el riesgo; sin embargo las de Norton y de Braden son las más utilizadas para la evaluación risk as to quantify the magnitude of each risk factor and have been tested extensively.
The Norton scale includes five variables: mental state, activity, mobility, continence and physical condition, each measured from highest to lowest values \u200b\u200bof four (4) to one (1) for a maximum total score of 20 . Total scores less than or equal to 12 classify people at high risk for developing pressure ulcers.

The Braden scale allows an early assessment, avoiding the occurrence of pressure sores, or minimizing their effects. Includes six variables: sensory perception, moisture, activity, mobility, nutrition, and friction and scaling each child is measured at greater than one (1) to four (4) except for the variable friction and scaling that you only have values \u200b\u200bof one (1) to three (3), for a total score maximum of 23. Total scores less than or equal to 12 classify people at high risk for developing pressure ulcers; total scores between 13 and 1410 classified as moderate risk if the score is between 15 v 16 "if it is less than 75 years or 15-18, greater than or equal to 75 years classified as risk management bajo.El mechanical loads helps reduce the magnitude of tissue pressure and the viability of soft tissue and skin, recommendations aim to reduce levels of pressure and friction to the movement favoring tisularExisten studies cited by Braden and Bergstrom, who have shown that spontaneous movements made by elderly patients in bed, affect the presence of pressure ulcers. Cynics trials where schedules are manipulated position changes, they conclude that those developed fewer pressure ulcers were those who were made position changes every 2 or 3 hours.
Team:

-Elements to relieve pressure, mattress foam, air cushions, pillows and foam wedges.

-Savannah movement. Absorbent diapers.

-Savers codas and heels.

-Movies

transparent and hydrocolloid dressings.

-Arc Balkan bath seat. The foam mattress is characterized by being made of a porous material, semi-rigid and spongy at the top is molded rough ovoid form so it is also called egg mattress. It is used to cushion the weight of the bony. Avoid the floats or pads with a hole in the center .
The semiocclusive transparent films (Tegaderm, Bioclusive, Opsite) membranes are sterile, hypoallergenic adhesive semipermeable and permeable to moisture vapor and oxygen, allows the exchange of this and prevent pollution since they are impervious to bacteria and liquids. Allows easily assess the wound as it can be seen through it and are used in patients at high risk of developing sores or pressure zones. This film is not removed unless it is apparent that this collection or lower it. Used in patients with stage I and II (abrasion and blisters to form epithelium). The
hydrocolloid dressings (DuoDERM, tegasarb) are impervious to oxygen, water activation contain particles that absorb exudate to form a hydrogel on the wound. This gel maintains a moist environment promotes self-analysis and prevents pollution. Not adhere to the newly formed tissue, the gel is separated from the dressing and prevent injuries. Should be changed every fourth day unless there is infection. They are useful in patients with stage II (ulceration superficial).

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PATHOGENESIS AND OTHER RISK FACTORS.

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The most important factor in the development of the UP is the pressure maintained. She can be associated frictional forces parallel and / or tangential, as well as a number of risk factors mainly depend on the patient's condition.
The UP require the existence of microcirculatory disorders in support areas of the body located on a hard surface. For this reason bony areas are the most frequent occurrence of UP. The pressure exerted on skin and soft tissue produces a interstitial pressure increased with obstruction of blood vessels (formation of microthrombi) and nodes, leading to autolysis and accumulation of toxic and metabolic waste. Prolonged local ischemia leads to necrosis and subsequent ulceration of tissues, both skin and deeper layers.

The hydrostatic pressure in skin capillaries between 16 and 32 mmHg. All these figures exceed pressure decreases blood flow and ischemic damage may occur even in less than two hours.
friction forces (frictional forces parallel to the epidermal surface) and shear (tangential forces increase friction in the areas of pressure when the head of the bed rises above 30 °), decrease the pressure required to cause tissue damage.
have described a series of risk factors in the onset of the UP dependent on the patient's condition. Of these immobility is the most important.
are factors that contribute to the production of ulcers and can be grouped into five major groups: 1
.- pathophysiological :
As a result of different health problems.
- Skin lesions: edema, dry skin, lack of elasticity. - Impaired Transportation Oxygen: peripheral vascular disorders, venous stasis, cardiopulmonary disorders ... - Nutritional Deficiencies (default or by excess): Thinness, malnutrition, Odessa, hypoproteinemia, dehydration .... - Immune disorders, cancer, infection ....... - Altered State of Consciousness: Stupor, confusion, coma ...... - Motor Impairments: paresis, paralysis ....... - Sensory Impairments: Loss of pain sensation .... - Altered Elimination (urine / bowel): urinary and bowel incontinence.
2 .- Derived Treatment :
As a result of certain therapies or diagnostic procedures.
- immobility Imposed as a result of certain alternative therapies, devices / equipment such as casts, traction, respirators .......... - Treatments or drugs that have action inmunopresora: Radiotherapy, corticosteroids, cytostatics ...... - Drilling for diagnostic and therapeutic: IUC, NG ...... 3 .-
Situation:
result of changes in personal, environmental, habits, etc.
- immobility, related to pain, fatigue, stress ..... - Wrinkle in linens, nightgown, pajamas, rubbing objects, etc. .. 4 .-
Developmental : Related
maturation.
- infants, the diaper rash ... - Elderly: Loss of skin elasticity, dry skin, restricted mobility ..... 5 .-
Environment:
- Deterioration of the individual's own image in the disease. - The lack of health education to patients. - The lack of uniform criteria in the planning of the priests by the medical team. - The lack or misuse of the material to prevent both the basic and the complementary. - The motivation for the lack of professional training and / or specific information. - Overwork professional.

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LOCATION AND CLASSIFICATION OF ULCERS. PRESSURE ULCERS

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are usually located usually support in areas that coincide with maximum relief or bony prominences. So the areas most susceptible to developing pressure ulcers are sacral region, the heel, ischial tuberosities and thighs.
we see in the image depending on the position the person has ulcers will develop in one area or another body.



A classification of ulcers which are 5 stages: Stage I

: Preúlcera. Epidermis intact, adherent and erythema which disappeared by relieving the pressure.


STAGE II: Epidermis intact and adherent. Possible presence of edema, and erythema decrease if you press and has more than 15 mm. diameter.





Stage III: Ecchymosis Cardinal in tissue or in an ampoule or dark under the skin of more than 5mm in diameter. Also a clear blister over 15 mm. in diameter.




STADIUM IV: Cold open surface, injuring the dermis and hypodermis, but dark colors more than 5mm in diameter.





STAGE V: deep pressure ulcer with exposed viscera, bone or tendon.