Pressure Ulcer Prevention and Management

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Pressure Ulcer Prevention and Management

• Dipti Jethani RN BSN
• Alverno College

All motion clips/images not labeled obtained
from Microsoft Clip Art
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Table of Contents
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Learning Objectives

• Learner will be able to identify the stages of
  pressure ulcers
• Learner will be able to identify patients at risk
  for pressure ulcers
• Learner will be able to identify 3 ways to
  decrease risk and incidence of pressure ulcers
• Learner will be able to identify 3 complications
  of pressure ulcers

5
Lets Start With A Case Study

• Grace is an 84 year old female who was recently
  admitted into the hospital with a diagnosis of
  Pneumonia.
• She has been weak, she used a cane before
  admittance in the hospital. She now is only
  mobile per wheel chair.
• She also is an uncontrolled Type II Diabetic
  (Non-Insulin Dependent)
• HOW WILL YOU PREVENT HER FROM DEVELOPING PRESSURE
  ULCERS?

Doheny, Patrick. (2007). Happy planet one.
Photograph. Retrieved from http//www.flickr.com
/photos/14132971_at_N05/1449122304/.
6
What Factor Most Puts Grace at Risk for Pressure
Ulcers?

• Age
• Lack of Mobility
• Diabetes
• Having Pneumonia
• Having a cane shell beat the nurses up!

Click Here To Read Case Study Narrative
7
THAT S RIGHT
8
SORRY TRY AGAIN
Although this is a good answer, there is another
answer more fitting than this one, try again.
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THE SKIN

• Three Layers
• Epidermis
• Outermost Layer
• Contains sensory receptors for pain, temp, touch,
  vibration, and pressure detection
• Barrier to preserve moisture, vitamins, minerals,
  and proteins
• Dermis
• Lies beneath the epidermis, deeper and thicker
  too
• Contains connective tissue, sebaceous glands
• Contains fat sweat glands
• Subcutaneous Tissue
• Layer of fat and connective tissue
• Layer of insulation to conserve body heat

National Pressure Ulcer Advisory Panel (2007).
For Educational Purposes.
Lippincott Williams and Wilkins, 2011
10
Lets Review What are pressure ulcers??

• Also known as Pressure/Bed Sores
• Areas of cellular necrosis and skin breakdown
  most common over bony prominences
• Can occur anywhere on the body
• Most Common Sites Sacrum, Heels

http//www.nlm.nih.gov/medlineplus/ency/imagepages
/19091.htm For Educational Purposes, NIH
Lippincott Williams and Wilkins, 2011
11
Incidence of Pressure Ulcers
Anders, 2010 Sage Products Inc (2003)
Mereck Manual of Geriatrics, 2000 Krasner
(2008).
12
Risk Factors

• Extrinsic Factors
• Pressure
• Friction
• Shearing
• Intrinsic Factors
• Immobility
• Inactivity
• Incontinence
• Malnutrition
• Age
• Mental Status

Mereck Manual of Geriatrics, 2000
13
Assessing the Risk

• BEGINS ON ADMISSION
• Skin Exam
• On admission and every shift
• History of Pressure ulcers
• Recent weight loss
• Mobility Status
• Urinary/Bowel Incontinence
• Dietary Intake/Nutr Status
• Use Scales For Assessment
• Braden Scale
• Norton Scale
• PUSH Tool

Guren, D., 2010.
14
Braden Scale
Cassell, 2009.
15
http//www.bradenscale.com/images/bradenscale.pdf
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Prevention

• BEGINS AT FIRST CONTACT
• Turn patient at least every 2 hours
• Do not place pts in a 90 degree lateral position
• Puts more pressure on greater trochanter and
  lateral malleolus
• Dont elevate HOB gt 30 degrees (except when
  eating) to minimize shearing forces
• Avoid Fluorescent Light, it casts a blue tint to
  skin (Capezuti, 2008)
• Check skin of high risk patients for changes in
• Color, turgor, temp, and sensation.

Mereck Manual of Geriatrics, 2000
17
Prevention Cont.

• Patient should not sit more than 2 hours
• Sitting position puts increased pressure on
  ischial tuberosities.
• Reposition patient every hour in chair
• Teach patient to shift weight every 15 minutes

• Do not use pillows/ rubber doughnuts
• Keep skin surface clean and dry (Meticulous skin
  care)
• As few pads as possible should be used
• Main Points
• Keep pressure off the area of breakdown
• Clean and dress the wound
• Maintain good nutrition

Mereck Manual of Geriatrics, 2000
18
Prevention

• Monitor Lab Values
• HgB lt12
• Total Lymphocyte Count lt1200
• Serum Albumin lt3.5
• Serum Transferrin lt170
• Promote Movement and Freq Position Changes

(Anders, 2010)
Mereck Manual of Geriatrics, 2000
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Pressure Relief Aids
Lippincott Williams and Wilkins, 2011
20
Pressure Points

• Most Develop Over 5 locations
• Sacral Area
• Greater Trochanter
• Ischial Tuberosity
• Heels
• Lateral Malleolus
• 90 occur in lower body

Agency for Health Care Policy and Research (2008)
Lippincott Williams and Wilkins, 2011 Abrass,
2004
21
Case Study

• Grace has a history of COPD and has smoked 1 PPD
  for 22 years, but quit 7 years ago.
• Her Diabetes has progressed and due to
  complications her Left foot was amputated.
• On the last shift a small Stage I pressure ulcer
  was also discovered.

22
What complication should the nurse most focus on
preventing?

• A. Progression of the Ulcer to a new stage
• B. Increased Length of Stay
• C. Infection
• D. Sepsis
• E. All of the Above
• F. A and B only

Click Here To Read Case Study Narrative
23
Stages of Pressure Ulcers

• 6 Stages
• Staged according to depth of damage

Bright Hub Inc, 2011. Public Domain Image
Mereck Manual of Geriatrics, 2000
24
Suspected Deep Tissue Injury

• Maroon or purple intact skin or a blood filled
  blister
• Cause shearing or pressure on the underlying
  soft tissue
• Before discoloration occurs, the area may be
• Painful
• Mushy, firm, or boggy
• Warmer or cooler as compared to other tissue

National Pressure Ulcer Advisory Panel (2007).
For Educational Purposes.
Abrass, 2004
25
Stage I

• An area of intact skin that does not blanch and
  is usually over a bony prominence.
• NON-BLANCHABLE
• Darkly pigmented skin may not show blanching but
  its color may differ from the surrounding area.
• The area may be painful, firm or soft, or warmer
  or cooler when compared to the surrounding
  tissue.

National Pressure Ulcer Advisory Panel (2007).
For Educational Purposes.
Abrass, 2004
26
Stage II

• A superficial partial thickness wound
• Presents as a shallow, open ulcer without slough
  and with a red and pink wound bed.
• This term shouldnt be used to describe
• Perineal dermatitis, maceration, tape burns, skin
  tears or excoriation .
• Only use to describe
• An abrasion, a blister, or a shallow crater that
  involves the epidermis and dermis.

National Pressure Ulcer Advisory Panel (2007).
For Educational Purposes.
Abrass, 2004
27
Stage III

• A full-thickness wound with tissue loss.
• The subcutaneous tissue may be visible but
  muscle, tendon, or bone is not exposed.
• Slough may be present but it does not hide the
  depth of the tissue loss.
• Undermining and tunneling may be present.
• Bone/Tendon are NOT visible

National Pressure Ulcer Advisory Panel (2007).
For Educational Purposes.
Abrass, 2004 NPUAP, 2007
28
Stage IV

• Involves Full-Thickness skin loss
• Can visibly see exposed muscle, bone, or tendon
• Eschar and sloughing may be present as well as
  undermining and tunneling

National Pressure Ulcer Advisory Panel (2007).
For Educational Purposes.
Abrass, 2004
29
Unstageable

• Involves full-thickness tissue loss.
• The base of the ulcer is covered by
• Slough yellow, tan, gray, green, or brown OR
• Eschar tan, brown, or black
• The pressure ulcer cannot be staged until enough
  eschar or slough is removed to expose the base of
  the wound

National Pressure Ulcer Advisory Panel (2007).
For Educational Purposes.
Abrass, 2004
30
Definitions

• Friction Surface damage caused by skin rubbing
  against
• another surface.
• Shearing Trauma to skin caused by tissue layers
  sliding against each other, results in disruption
  of blood vessels.
• Maceration Softening of tissue by soaking in
  fluids.
• Debridement Removal of damaged tissue.
• Eschar Thick, leathery necrotic tissue damaged
  tissue.
• Slough Loose, stringy necrotic tissue
• Undermining Tissue destruction underlying intact
  skin
• along wound edges.
• Tunneling A narrow channel/passageway extending
  into
• healthy tissue.

Oklahoma Foundation for Medical Quality, 2009
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Case Study Cont.

• Which of the following is Grace most at risk for?
  
• Friction
• Shearing
• Maceration
• Laceration

Click Here To Read Case Study Narrative
32
Case Study
Click Here To Read Case Study Narrative

• Grace became incontinent of bowel and bladder.
• She has a decreased appetite and has become more
  confused since the last shift.
• A urine specimen was obtained and results show
  she has a UTI.

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What measures can you take to prevent progression
and development of pressure ulcers?
34
Pathophysiology

• Affected area becomes hypoxic and ischemic d/t
  press exerted on it
• ?
• Decreased blood flow to site
• ?
• Capillaries Collapse, Thrombosis occurs
• ?
• Tissue Edema/Necrosis
• ?
• Accumulation of waste products at site
• ?
• Tissue Breakdown
• ?
• Cell Death

Lippincott Williams and Wilkins, 2011
35
Stress Response and Pressure Ulcers

• Stress occurs
• ?
• Adrenal Glands produce Epi
• ?
• SNS releases NE
• ?
• NE causes peripheral vasoconstriction
• ?
• Decreased Oxygen Delivery
• ?
• Epi enhances production of chalone
• ?
• Chalone protein depresses regeneration of
  epidermal tissue
• ?
• Tissue Breakdown
• ?
• Cell Death

Epi Epinephrine NE Norepinephrine
Place mouse over chalone to see definition
Maklebust, J., Sieggreen, M. (2001).
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Aging

• Muscle fat are lost with aging (to spread out
  press)
• Skin Elasticity Decreases
• ? in ascorbic acid levels
• BVs Connective tx more fragile
• Lowers threshold of pressure injury

• ? in of Dermal BVs
• Incr risk of ischemic injury by press and
  shearing forces
• Wound healing ?ed
• Repair rate declines
• Cell proliferation ?es
• Wound tensile strength ?es
• Collagen deposition ?es

Lippincott Williams and Wilkins, 2011 Mereck
Manual of Geriatrics, 2000
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Inflammation

• Damaged BVs
• ?
• Exposed Collagen
• ?
• With Thrombin exposed collagen stimulates
  platelet activity
• ?
• Activation, aggregation, and adhesion of
  platelets and release mediators
• ?
• Stimulates Vasoactive substances
• ?
• Breakdown products attract nuetrophils and
  macrophages
• ?
• Monocytes become Macrophages
• ?
• Release growth factors
• ?
• Trigger Fibroblasts to secrete collagen
  proteins
• ?
• Wound becomes beefy red and bleeds

Hulse, 2011
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Genetics

• Study by Bregstorm Braden (2002)
• found A.A. lowest risk for Stage I ulcers
  Caucasians at highest risk for developing Stage I
  ulcer
• For stages II-IV AA most at risk for progression
  of an ulcer Caucasians least at risk
• Certain Medical Conditions
• Diabetes M.
• Peripheral Vascular Dx
• Predisposed to developing pressure sores

Capezuti, 2008
Mereck Manual of Geriatrics, 2000
39
Pressure Ulcers on Heels

• Account for 20 of all pressure ulcers
• Easy to acquire hard to heal
• Pressure relief
• Pillows (floating)
• Heel Protector Boots
• Dressing if necessary
• Foam Pads

Guren, D., 2010.
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Complications

• Progression of pressure ulcer
• Secondary Infections
• Ex. Sepsis, Cellulitis
• Osteomyelitis ?Loss of limb from bone involvement
• Marjolins Ulcer
• Squamous cell carcinoma within the ulcer
• Increased Length of Stay
• Increased Costs
• Death

Lippincott Williams and Wilkins, 2011
Mereck Manual of Geriatrics, 2000 Capezuti, 2008
41
Treatment

• Prevention Strategies
• Pressure Reduction
• Avoiding Friction/ Shearing Forces
• Stage III/IV
• Debridement of necrotic tissue
• Freq Irrigation (2-3x/d)
• Dressing of the wound
• Encourage movement

Abrass, 2004 Anders, 2010
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POP QUIZ

• Identify the pressure ulcer stage of the
  following area of skin abnormality .

Public Domain Image obtained from
http//i.ytimg.com/vi/QvcjH98ipeU/2.jpg
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• IF YOU SAID
• STAGE III
• YOU WERE RIGHT!!

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Nutrition

• Need adequate intake for wound healing and immune
  response
• Incr protein/caloric intake
• Supplement with multi-vitamins (A C)
• Consult with a Dietician
• Loss of gt 15 of lean body mass interferes with
  wound healing
• Immune Function Loss
• gt Incr risk of infection and decr wound healing

Anders, 2010 Maklebust, J., 2001
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Nursing Implications
Krasner, 2008
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Documentation

• Location
• Size
• Dressing
• Type of irrigation soln, drsg applied
• Drainage
• Amt, color, odor
• Undermining/Tunneling Present
• Infection s/s
• Character of wound
• Presence of slough, granulation tissue, etc
• Pressure relieving measures used

Hill Rom Services Inc., 2007
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CASE STUDY CONT.

• What aspect of Graces existing condition is the
  most influencing factor for increasing her risk
  for pressure ulcers?
• Pneumonia/COPD
• Diabetes
• Venous Insufficiency
• Lack of Mobility
• None of the Above
• All of the Above

Click Here To Read Case Study Narrative
48
Case Study Conclusions

• Press ulcers can increase morbidity and risk for
  complications
• Grace represents a typical patient
• Documentation and thorough assessment is a
  necessity
• FOR A VIRTUAL TOUR OF SKIN BREAKDOWN SEE NEXT
  SLIDE

Doheny, Patrick. (2007). Happy planet one.
Photograph. Retrieved from http//www.flickr.com
/photos/14132971_at_N05/ 1449122304/.
49
http//www.youtube.com/watch?vEyuguc7KKC4feature
player_embeddedat61 (Click here to see video)
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Did you meet the objectives??

• Identify the stages of pressure ulcers
• Identify patients at risk for pressure ulcers
• Identify 3 ways to decrease risk and incidence of
  pressure ulcers (prevention)
• Identify 3 complications of pressure ulcers

Click the link if you want to review!
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TRY AND RUN WITH IT
Questions? Email jethandr_at_alverno.edu
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References

• Abrass, I., Kane, R., Ouslander, J. (2004).
  Essentials of Clinical Geriatrics. (5th ed.).
  McGraw Hill-Companies, Inc.Hightstown, NJ.
• Agency for Health Care Policy and Research
  (2008). AHCPR Supported Guide and Guidelines
  Internet. Rockville MD. Retrieved on April 2,
  2011 from http//www.ncbi.nlm.nih.gov/books/NBK17
  977/.
• Anders, J., Heinemann, A., Leffmann, C.,
  Leutenegger, M., Profener, F.,
  Von-Rentein-Kruse, W. (2010). Decubitus Ulcers
  Pathophysiology and Primary Prevention.
  Deutsches Arzteblatt International, 107 (21)
  371-82.
• Aurora Health Care (2010). Skin Integrity
  Alterations Potential/Actual for Adult
  Inpatients. Milwaukee, WI Aurora HealthCare.
• Bright Hub Inc. (2011). Healing Bedsores.
  Retrieved on April 2, 2011 from http//www.bright
  hub.com/health/alternativemedicine/articles/52007.
  aspx.
• Capezuti, E., Fulmer, T., Mezey, M., Zwicker,
  D. (2003). Evidenced Based Geriatric Nursing
  Protocols For Best Practice. (3rd ed). Springer
  Publishing Co., New York, NY.
• Cassell, C. (2009). Pressure Ulcer Assessment
  The Braden Scale for Predicting Pressure Ulcer
  Sore Risk. Health Services Advisory Group.
• Guren, D. (2010). Skin is in positioning your
  surgical patient matters. Retrieved March 28,
  2011 from http//uwcne.net/grandrounds/display.asp
  ?ID48 submitVideo.

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References Cont

• Hill-Rom Services Inc. (2007). Guidelines for
  staging of pressure ulcers. Brochure.
• Hulse, J. (2011). Skin and Wound Care. Pesi
  Health Care. Confrence.
• Krasner, D., McNeil, M., Weir, D. (2008). The
  Pressures On Getting it Right on Admission.
  Norcross, GA Molnlycke Health Care.
• Lippincott. (2011). Professional Guide to
  Pathophysiology (3rd ed.). Lippincott Williams
  and Wilkins. Ambler, PA.
• Maklebust, J., Sieggreen, M. (2001). Pressure
  Ulcers Guidelines for Prevention and
  Management. (3rd ed.). Ambler, PA. Lipponcott
  Williams and Wilkins.
• Molnlycke Health Care (2007). Mepilex Border
  Sacrum. Brochure. Norcross, GA.
• National Pressure Ulcer Advisory Panel. (2007).
  Pressure Ulcer Category/Staging Illustrations.
  Retrieved on April 1, 2011 from
  http//www.npuap.org/resources.htm.
• Nucleus Medical Media. (2011). Pressure Sores
  youtube video Retreived from http//www.youtube.
  com/watch?vEyuguc7KKC4featureplayer_
  embeddedat61.

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References Cont.

• Oklahoma Foundation for Medical Quality. (2009 ).
  Appendix A Glossary Pressure Ulcer Terms.
  Retrieved on April 10, 2011 from http//
  www.ofmq.com/Websites/ofmq/Images/SOS20PU20Tool
  kit/Appe ndix20A.pdf .
• Porth, C., Matfin, G. (2009). Pathophysiology
  Concepts of Altered Health States (p. 38-46).
  Philadelphia, PA Lippincott Williams Wilkins.
• Sage Products Inc. (2003). What the experts say
  about the financial implications of pressure
  ulcers. Brochure. Cary, Il.
• The Merck Manual of Geriatrics 3rd Edition
  (2000), (pp. 1317-1322). Whitehouse Station, NJ
  Merck Research Laboratories.
• US Dept of Health Human Services, National
  Institutes of Health (2010). Areas Where
  Bedsores Occur. Online Image. Retrieved on
  April 1, 2011 from http//www.nlm.nih.gov/medline
  plus/ency/imagepages /19091.htm.