Presentation on theme: "Pressure Ulcer Prevention and Management"— Presentation transcript:
1 Pressure Ulcer Prevention and Management Dipti Jethani RN BSNAlverno CollegeAll motion clips/images not labeled obtained from Microsoft Clip Art
2 Navigation NEXT SLIDE PREVIOUS SLIDE LAST SLIDE VIEWED HOME /TABLE OF CONTENTSLAST SLIDE VIEWED
3 Table of Contents Navigation Objectives Incidence Risk Factors Stages of UlcersPreventionPathophysiologyComplicationsTreatment
4 Learning ObjectivesLearner will be able to identify the stages of pressure ulcersLearner will be able to identify patients at risk for pressure ulcersLearner will be able to identify 3 ways to decrease risk and incidence of pressure ulcersLearner will be able to identify 3 complications of pressure ulcers
5 Let’s 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
6 What Factor Most Puts Grace at Risk for Pressure Ulcers? AgeLack of MobilityDiabetesHaving PneumoniaHaving a cane – she’ll beat the nurses up!Click Here To ReadCase Study Narrative
8 SORRY TRY AGAINAlthough this is a good answer, there is another answer more fitting than this one, try again.
9 THE SKIN Three Layers Epidermis Dermis Subcutaneous Tissue Outermost LayerContains sensory receptors for pain, temp, touch, vibration, and pressure detectionBarrier to preserve moisture, vitamins, minerals, and proteinsDermisLies beneath the epidermis, deeper and thicker tooContains connective tissue, & sebaceous glandsContains fat &sweat glandsSubcutaneous TissueLayer of fat and connective tissueLayer of insulation to conserve body heatNational Pressure Ulcer Advisory Panel (2007).For Educational Purposes.Lippincott Williams and Wilkins, 2011
10 Let’s Review… What are pressure ulcers?? Also known as: Pressure/Bed SoresAreas of cellular necrosis and skin breakdown most common over bony prominencesCan occur anywhere on the bodyMost Common Sites: Sacrum, HeelsFor Educational Purposes, NIHLippincott Williams and Wilkins, 2011
11 Incidence of Pressure Ulcers Estimated: 1 mill/yr; annual cost = $1.6 billionThe elderly account for > 60% of decubitus patientsSince 2008, hospitals are not able to be reimbursed for the care of Stage III or IV pressure ulcers that the patient acquires during their hospital stay63% increase in hospitalized patients with pressure ulcers between 1993 and 2003There has been no sig decrease in pressure ulcers in the last 10 yearsMost often seen in elderlyBedridden; Chair Bound9 out of 10 patients were covered by a government program (Medicare or Medicaid)In 2007, CMS reported 257,412 cases of preventable pressure ulcers as secondary diagnosesAnders, 2010; Sage Products Inc (2003)Mereck Manual of Geriatrics, 2000; Krasner (2008).
13 Assessing the Risk BEGINS ON ADMISSION Skin Exam On admission and every shiftHistory of Pressure ulcersRecent weight lossMobility StatusUrinary/Bowel IncontinenceDietary Intake/Nutr StatusUse Scales For AssessmentBraden ScaleNorton ScalePUSH ToolGuren, D., 2010.
14 Braden ScaleUsed to accurately predict who will develop pressure ulcers6 Areas of Assessment: Sensory Perception, Activity, Mobility, Skin Moisture, Nutritional Intake, Friction and ShearScored from 1-41 for low level of functioning and 4 for the highest level or no impairmentTotal scores range from 6-23At Risk (15-18)Moderate Risk (13-14)High Risk (10-12)Very High Risk (9 or below)Cassell, 2009.
16 Prevention BEGINS AT FIRST CONTACT Turn patient at least every 2 hours Do not place pts in a 90 degree lateral positionPuts more pressure on greater trochanter and lateral malleolusDon’t elevate HOB > 30 degrees (except when eating) to minimize shearing forcesAvoid 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 chairTeach patient to shift weight every 15 minutesDo not use pillows/ rubber doughnutsKeep skin surface clean and dry (Meticulous skin care)As few pads as possible should be usedMain Points:Keep pressure off the area of breakdownClean and dress the woundMaintain good nutritionMereck Manual of Geriatrics, 2000
18 Prevention Monitor Lab Values: HgB <12 Total Lymphocyte Count <1200Serum Albumin <3.5Serum Transferrin <170Promote Movement and Freq Position ChangesMereck Manual of Geriatrics, 2000(Anders, 2010)
19 Pressure Relief Aids Lippincott Williams and Wilkins, 2011 Gel Flotation PadsSheep SkinHeel BootsLow Air Loss BedAir-Fluidized BedSpanco MattressConvoluted Foam MattressAlternating Pressure MattressLippincott Williams and Wilkins, 2011
20 Pressure Points Most Develop Over 5 locations: 90% occur in lower body Sacral AreaGreater TrochanterIschial TuberosityHeelsLateral Malleolus90% occur in lower bodyAgency for Health Care Policy and Research (2008)Lippincott Williams and Wilkins, 2011; Abrass, 2004
21 Case StudyGrace 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 onlyClick Here To ReadCase Study Narrative
23 Stages of Pressure Ulcers Staged according to depth of damageBright Hub Inc, Public Domain ImageMereck Manual of Geriatrics, 2000
24 Suspected Deep Tissue Injury Maroon or purple intact skin or a blood filled blisterCause: shearing or pressure on the underlying soft tissueBefore discoloration occurs, the area may be:PainfulMushy, firm, or boggyWarmer or cooler as compared to other tissueNational Pressure Ulcer Advisory Panel (2007).For Educational Purposes.Abrass, 2004
25 Stage IAn area of intact skin that does not blanch and is usually over a bony prominence.NON-BLANCHABLEDarkly 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 shouldn’t be used to describe:Perineal dermatitis, maceration, tape burns, skin tears or excoriation .Only use to describeAn 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 visibleNational 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 tendonEschar and sloughing may be present as well as undermining and tunnelingNational 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 OREschar: tan, brown, or blackThe pressure ulcer cannot be staged until enough eschar or slough is removed to expose the base of the woundNational 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 tissueUndermining: Tissue destruction underlying intact skinalong wound edges.Tunneling: A narrow channel/passageway extending intohealthy tissue.Oklahoma Foundation for Medical Quality, 2009
31 Case Study Cont. Which of the following is Grace most at risk for? FrictionShearingMacerationLacerationClick Here To ReadCase Study Narrative
32 Case Study Grace became incontinent of bowel and bladder. Click Here To ReadCase Study NarrativeGrace 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.
33 What measures can you take to prevent progression and development of pressure ulcers?
34 PathophysiologyAffected 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 DeathLippincott 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 DeathEpi = Epinephrine NE = NorepinephrinePlace mouse over chalone to see definitionMaklebust, J., & Sieggreen, M. (2001).
36 Aging Muscle & fat are lost with aging (to spread out press) Skin Elasticity Decreases in ascorbic acid levels:BVs & Connective tx more fragileLowers threshold of pressure injury in # of Dermal BVs:Incr risk of ischemic injury by press and shearing forcesWound healing ed:Repair rate declinesCell proliferation esWound tensile strength esCollagen deposition esLippincott Williams and Wilkins, 2011; Mereck Manual of Geriatrics, 2000
37 InflammationDamaged 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 Vasculature begins to restoreHulse, 2011
38 Genetics Study by Bregstorm & Braden (2002) Certain Medical Conditions found A.A. lowest risk for Stage I ulcers & Caucasians at highest risk for developing Stage I ulcerFor stages II-IV AA most at risk for progression of an ulcer & Caucasians least at riskCertain Medical ConditionsDiabetes M.Peripheral Vascular DxPredisposed to developing pressure soresCapezuti, 2008Mereck Manual of Geriatrics, 2000
39 Pressure Ulcers on Heels Account for 20% of all pressure ulcersEasy to acquire hard to healPressure reliefPillows (floating)Heel Protector BootsDressing if necessaryFoam PadsGuren, D., 2010.
40 Complications Progression of pressure ulcer Secondary Infections Ex. Sepsis, CellulitisOsteomyelitis Loss of limb from bone involvementMarjolin’s UlcerSquamous cell carcinoma within the ulcerIncreased Length of StayIncreased CostsDeathLippincott Williams and Wilkins, 2011Mereck Manual of Geriatrics, 2000; Capezuti, 2008
41 Treatment Encourage movement Prevention Strategies Pressure Reduction Avoiding Friction/ Shearing ForcesStage III/IVDebridement of necrotic tissueFreq Irrigation (2-3x/d)Dressing of the woundEncourage movementAbrass, 2004; Anders, 2010
42 POP QUIZIdentify the pressure ulcer stage of the following area of skin abnormality .Public Domain Image obtained from:
44 Nutrition Need adequate intake for wound healing and immune response Incr protein/caloric intakeSupplement with multi-vitamins (A & C)Consult with a DieticianLoss of > 15% of lean body mass interferes with wound healingImmune Function Loss=> Incr risk of infection and decr wound healingAnders, 2010; Maklebust, J., 2001
45 Nursing Implications Krasner, 2008 Diligent assessment and documentation of the condition of the skin of all patientsUse of supplements and feeding assistance devices as neededONLY pressure ulcers should be st aged; Wounds of other etiologies:(venous insufficiency, arterial, diabetic/neuropathic foot ulcers, trauma, etc) should be described as partial or full thickness or other appropriate system of documentationPressure ulcers are not staged in a reverse mannerEx. A Stage IV does not progress to a Stage III, II or I.The stage remains the same throughout the healing process.In deeper stages (Stage III and IV) tissue destroyed is replaced by granulation tissue and ultimately scarKrasner, 2008
46 Documentation Location Size Dressing Type of irrigation soln, drsg appliedDrainageAmt, color, odorUndermining/Tunneling PresentInfection s/sCharacter of woundPresence of slough, granulation tissue, etcPressure relieving measures usedHill Rom Services Inc., 2007
47 CASE STUDY CONT.What aspect of Grace’s existing condition is the most influencing factor for increasing her risk for pressure ulcers?Pneumonia/COPDDiabetesVenous InsufficiencyLack of MobilityNone of the AboveAll of the AboveClick Here To ReadCase Study Narrative
48 Case Study Conclusions Press ulcers can increase morbidity and risk for complicationsGrace represents a typical patientDocumentation and thorough assessment is a necessityFOR A VIRTUAL TOUR OF SKIN BREAKDOWN SEE NEXT SLIDEDoheny, Patrick. (2007). Happy planet one. [Photograph]. Retrieved from /.
49 http://www. youtube. com/watch (Click here to see video)
50 Did you meet the objectives?? Identify the stages of pressure ulcersIdentify patients at risk for pressure ulcersIdentify 3 ways to decrease risk and incidence of pressure ulcers (prevention)Identify 3 complications of pressure ulcersClick the link if you wantto review!
52 ReferencesAbrass, 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 fromAnders, 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):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 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 submit=Video.
53 References ContHill-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 Pressure’s 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 fromNucleus Medical Media. (2011). Pressure Sores [youtube video] Retreived from embedded#at=61.
54 References Cont.Oklahoma Foundation for Medical Quality. (2009 ). Appendix A: Glossary – Pressure Ulcer Terms. Retrieved on April 10, 2011 from ndix%20A.pdf .Porth, C., & Matfin, G. (2009). Pathophysiology Concepts of Altered Health States (p ). 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 ). 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, from /19091.htm.