Interventions
1. Identify those at risk of developing this condition. Put in preventative measures such as appropriate positioning, active and passive range of motion exercises, pressure relief devices, adequate nutrition, and developing a plan for skin care.
2. Keep skin dry and sheets wrinkle-free, if client is incontinent, check client frequent and remove soiled items immediately. Use creams and lotions to lubricate and act as barrier protection for incontinent clients.
3. Assess skin, monitor for changes in skin integrity. Use proper assessment protocols such as recording exudates, undermining, size of wound, etc and management of a wound such as using using a wound dressing, and debridement.
4. Serosangeuineous exudate is expected for the first 48 hours, purulent exudates indicate colonization of the wound with bacteria.
5. Treatments may include skin grafting, electrical stimulation to the wound area , vacuum assisted wound closure, hyperbaric oxygen therapy and the use of opical growth factors