Pressure‐Ulcer & Neuro-Injury Nursing Care – Lecture Notes

Patient Repositioning & Pressure‐Ulcer Prevention

  • Reposition every 1–2 hr to off-load pressure, especially for patients who require frequent “boosts” up in bed.
  • Use proper sheets (full draw-sheets) to lift rather than drag; minimizes shear and friction injuries.

Braden Scale: Frequency & Rationale

  • Perform Braden pressure-injury risk assessment at least once per shift.
    • Risk score can fluctuate within the same shift as the patient’s condition changes (e.g., decreased mobility after medication, improved nutrition after meals, etc.).

Shear, Friction & Head-of-Bed (HOB) Angle

  • Recommended routine HOB angle: ≤ 30∘30^{\circ} when clinically possible to reduce shear.
  • Exception: raise HOB to eating position (≈ 60∘60^{\circ}) for meals, then return to ≤30∘\le 30^{\circ} promptly.
    • Rationale: higher angles encourage gravity-driven “sliding” toward the foot of bed, concentrating weight and shear on the sacrum/buttocks.

Case Study: Mrs. Johnson

  • 78-year-old patient develops a Stage 2 pressure ulcer on the sacrum.
  • Clinical takeaway: even with vigilant care, risk remains high in elderly; underscores need for strict Braden monitoring and HOB management.

Transmission-Based Precautions (Infection Control)

  • Four common categories mentioned:
    • Contact
    • Contact Plus (enhanced contact, often for pathogens like C. diff)
    • Droplet
    • Airborne
  • No specific questions raised by the group; consensus that concepts were understood.

Neuro Topic Introduction: Intracranial Pressure (ICP)

  • Transition from skin integrity to neuro: emphasis on recognizing & preventing rises in ICP for head-injured patients.

Skull-Fracture Warning Signs

  • Battle Sign
    • Bruising located behind the ear (mastoid area).
    • Pathognomonic for a basilar skull fracture.
  • “Raccoon Eyes”
    • Periorbital ecchymosis resembling black eyes.
    • Begins faint, darkens over time; accompanies basilar fractures.

Positioning After Head Injury

  • Maintain patient sitting up; avoid flat supine position.
  • Goal: promote venous drainage and limit elevation of ICP.

Activities That Increase ICP (to be avoided)

  • Sneezing
  • Tooth-brushing (vigorous)
  • Bending over (e.g., to tie shoes)
  • Lying flat

Pharmacologic Intervention

  • Dexamethasone (Decadron)
    • Spelling acknowledged: d e x a m e t h a s o m e
    • Classification: corticosteroid
    • Purpose: decrease cerebral inflammation ⇒ lower ICP
  • Not presented as an exhaustive drug list; highlighted as one of the most common agents used.

Traumatic Brain Injury (TBI) Assessment Prompt

  • Lecture concluded with a lead-in question: “Which assessment techniques are used to determine the physiological manifestations of a traumatic brain…”.
    • Full answer not provided within transcript snippet, signifying upcoming discussion.