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Dipti Jethani RN BSN Alverno College All motion clips/images not labeled obtained from Microsoft Clip Art.

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Presentation on theme: "Dipti Jethani RN BSN Alverno College All motion clips/images not labeled obtained from Microsoft Clip Art."— Presentation transcript:

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2 Dipti Jethani RN BSN Alverno College All motion clips/images not labeled obtained from Microsoft Clip Art

3 NEXT SLIDE PREVIOUS SLIDE HOME /TABLE OF CONTENTS LAST SLIDE VIEWED

4 NavigationObjectivesIncidence Risk FactorsStages of UlcersPrevention PathophysiologyComplicationsTreatment

5  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

6  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

7 a. Age Age b. Lack of Mobility Lack of Mobility c. Diabetes Diabetes d. Having Pneumonia Having Pneumonia e. Having a cane – she’ll beat the nurses up! Having a cane – she’ll beat the nurses up! Click Here To Read Case Study Narrative

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9 Although this is a good answer, there is another answer more fitting than this one, try again.

10  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 Lippincott Williams and Wilkins, 2011 National Pressure Ulcer Advisory Panel (2007). For Educational Purposes.

11  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 1.htm For Educational Purposes, NIH Lippincott Williams and Wilkins, 2011

12 Mereck Manual of Geriatrics, 2000; Krasner (2008). Anders, 2010; Sage Products Inc (2003) Estimated: 1 mill/yr; annual cost = $1.6 billion 63% increase in hospitalized patients with pressure ulcers between 1993 and 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 diagnoses There has been no sig decrease in pressure ulcers in the last 10 years The elderly account for > 60% of decubitus patients Since 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 stay Most often seen in elderly Bedridden; Chair Bound

13  Extrinsic Factors  Pressure  Friction  Shearing  Intrinsic Factors  Immobility  Inactivity  Incontinence  Malnutrition  Age  Mental Status Mereck Manual of Geriatrics, 2000

14  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.

15 Cassell, Used to accurately predict who will develop pressure ulcers 6 Areas of Assessment: Sensory Perception, Activity, Mobility, Skin Moisture, Nutritional Intake, Friction and Shear Scored from for low level of functioning and 4 for the highest level or no impairment Total scores range from 6-23 At Risk (15-18) Moderate Risk (13-14) High Risk (10-12) Very High Risk (9 or below)

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17  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  Don’t elevate HOB > 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

18  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

19  Monitor Lab Values:  HgB <12  Total Lymphocyte Count <1200  Serum Albumin <3.5  Serum Transferrin <170  Promote Movement and Freq Position Changes Mereck Manual of Geriatrics, 2000 (Anders, 2010)

20 Lippincott Williams and Wilkins, 2011 Gel Flotation Pads Sheep SkinHeel Boots Low Air Loss Bed Air-Fluidized Bed Spanco Mattress Convoluted Foam Mattress Alternating Pressure Mattress

21  Most Develop Over 5 locations:  Sacral Area  Greater Trochanter  Ischial Tuberosity  Heels  Lateral Malleolus  90% occur in lower body Lippincott Williams and Wilkins, 2011; Abrass, 2004 Agency for Health Care Policy and Research (2008)

22  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.

23 A. Progression of the Ulcer to a new stageProgression of the Ulcer to a new stage B. Increased Length of StayIncreased Length of Stay C. InfectionInfection D. SepsisSepsis E. All of the AboveAll of the Above F. A and B onlyA and B only Click Here To Read Case Study Narrative

24  6 Stages  Staged according to depth of damage  Mereck Manual of Geriatrics, 2000 Bright Hub Inc, Public Domain Image

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

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

27  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 describe  An abrasion, a blister, or a shallow crater that involves the epidermis and dermis. Abrass, 2004 National Pressure Ulcer Advisory Panel (2007). For Educational Purposes.

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

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

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

31  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

32  Which of the following is Grace most at risk for? a. Friction Friction b. Shearing Shearing c. Maceration Maceration d. Laceration Laceration Click Here To Read Case Study Narrative

33  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. Click Here To Read Case Study Narrative

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35 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

36 Stress occurs  Adrenal Glands produce Epi  SNS releases NE  NE causes peripheral vasoconstriction  Decreased Oxygen Delivery  Epi enhances production of chalone chalone  Chalone protein depresses regeneration of epidermal tissue  Tissue Breakdown  Cell Death Maklebust, J., & Sieggreen, M. (2001). Epi = Epinephrine NE = Norepinephrine Place mouse over chalone to see definition

37  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

38 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  Vasculature begins to restore Hulse, 2011

39  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, 2008Mereck Manual of Geriatrics, 2000

40  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.

41  Progression of pressure ulcer  Secondary Infections  Ex. Sepsis, Cellulitis  Osteomyelitis  Loss of limb from bone involvement  Marjolin’s Ulcer  Squamous cell carcinoma within the ulcer  Increased Length of Stay  Increased Costs  Death Lippincott Williams and Wilkins, 2011Mereck Manual of Geriatrics, 2000; Capezuti, 2008

42  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

43 Identify the pressure ulcer stage of the following area of skin abnormality. Public Domain Image obtained from:

44 IF YOU SAID: STAGE III YOU WERE RIGHT!!

45  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 > 15% of lean body mass interferes with wound healing  Immune Function Loss  => Incr risk of infection and decr wound healing Anders, 2010; Maklebust, J., 2001

46 Krasner, 2008 Diligent assessment and documentation of the condition of the skin of all patients Use of supplements and feeding assistance devices as needed ONLY 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 documentation Pressure ulcers are not staged in a reverse manner Ex. 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 scar

47  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

48  What aspect of Grace’s existing condition is the most influencing factor for increasing her risk for pressure ulcers? a. Pneumonia/COPD Pneumonia/COPD b. Diabetes Diabetes c. Venous Insufficiency Venous Insufficiency d. Lack of Mobility Lack of Mobility e. None of the Above None of the Above f. All of the Above All of the Above Click Here To Read Case Study Narrative

49  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 /

50 er_embedded#at=61http://www.youtube.com/watch?v=Eyuguc7KKC4&feature=play er_embedded#at=61 (Click here to see video)

51  Identify the stages of pressure ulcersstages of pressure ulcers  Identify patients at risk for pressure ulcers Identify patients at risk  Identify 3 ways to decrease risk and incidence of pressure ulcers (prevention)incidenceprevention  Identify 3 complications of pressure ulcerscomplications

52 Questions?

53  Abrass, I., Kane, R., Ouslander, J. (2004). Essentials of Clinical Geriatrics. (5 th 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  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):  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. (3 rd 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.

54  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 Pressure’s On: Getting it Right on Admission. Norcross, GA: Molnlycke Health Care.  Lippincott. (2011). Professional Guide to Pathophysiology (3 rd ed.). Lippincott Williams and Wilkins. Ambler, PA.  Maklebust, J., & Sieggreen, M. (2001). Pressure Ulcers: Guidelines for Prevention and Management. (3 rd 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  Nucleus Medical Media. (2011). Pressure Sores [youtube video] Retreived from embedded#at=61.

55  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, 2011 from /19091.htm.


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