Presentation on theme: "PREVENTION AND TREATMENT OF PRESSURE ULCERS"— Presentation transcript:
1PREVENTION AND TREATMENT OF PRESSURE ULCERS ByHolly Ferguson, PT, WCC
2PURPOSEThe purpose of this self-learning module is to help guide nurses performing skin assessment and care according to best practice.At the end of the module, the nurse will be able to:Identify skin assessment protocolIdentify risk factors for developing pressure ulcersIdentify at least 3 things to help prevent pressure ulcersIdentify the SJH nursing and interdisciplinary team resourcesIdentify ways to manage and treat pressure ulcers
5NPUAP DEFINITION (National Pressure Ulcer Advisory Panel) a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.
6PRESSURE ON VESSELSUnrelieved pressure on the skin squeezes tiny blood vessels, which supply the skin with nutrients and oxygen. When the skin is starved for too long, the tissue dies, and a pressure ulcer develops
9CLINICAL PRESENTATION Rounded, crater like shapes with regular edgesOver bony prominences, but can take on the shape of the bone (malleoli vs sacrum)Usually dark regular base that do not bleed easily95% over sacrum/coccyx, trochanter, IT, heel and lateral malleoli
10STATISTICS 70% occur in people over 65 Most common sites SACRUM AND HEELSShoulder, heel, and ear were the favorite sites of newly developed PrUs
12STAGES/PROGRESSION 4 stages depending on amount and time of ischemia Hyperemia (redness) will occur within 30 minutes of sustained pressure. If the Pressure is removed the hyperemia will disappear in approximately hoursDepending on a number factors (including general health) ischemia begins in 2-6 hours of sustained pressureTexture usually feels hardNecrosis begins ~6 hours after sustained pressure.At this stage skin appears blue or greyish and may be indurated. Recovery at this stage is variable.Finally, if pressure continues, ulceration occurs.
15Pressure Ulcer Staging STAGE 1: Skin is intact and shows a non blanchable, localized redness over a bony prominence. Redness remains after pressure is released. Signs and symptoms may include pain, firm, soft, warm or cool compared to adjacent tissue. – EPIDERMISSTAGE 2: Considered partial thickness wound. Superficial break in the epidermis or partial thickness loss of dermis. Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Bruising indicates suspected deep tissue injury.STAGE 3: Skin break with deep tissue involvement down to subcutaneous layer. Full thickness tissue loss. Subcutaneous fat may be visible. Bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.STAGE 4: Skin break with deep tissue involvement down to the bone, tendon, or muscle. Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Stage 3 and 4 are considered Full Thickness wounds.
17Pressure Ulcer Staging Unstageable: Full thickness tissueloss in which the base of the ulceris covered by slough (yellow, tan,gray, green or brown) and/oreschar (tan, brown or black)in the wound bed.Suspected Deep Tissue Injury (SDTI):Skin is purple. Level of tissuenecrosis is suspected to be deep.
18*difference between stage II and stage III – stage II will never have slough *Never back stage a PrU; document a “healing stage III” not a “stage II”
19HEELS Second most common site for PrU’s, and most common site of DTI Color reflects the degree of DTI:Red - hyperemia and ischemiaPurple – infarctionBlack - necrosis
20UNAVOIDABLE PRESSURE ULCERS According to NPUAP: An individual develops a PrU even thought the provider had evaluated the individual’s clinical condition and pressure ulcer risk factors’ defined and implemented interventions that are consistent with individual needs, goals and recognized standards practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate“Kennedy Terminal Ulcers”
21KENNEDY TERMINAL ULCERS Ulcers that some people get as they are dyingUsually on the sacrumUsually pear shapedColors varyIrregular bordersCome on suddenlyGeriatric phenomenon
22KENNEDY TERMINAL ULCERS CONTINUED Often confused for dirt or dried stool in the beginning, and providers try to wash it off only to find it is under the skinIn the beginning it can look like the skin got scraped off in a bad abrasionProgresses rapidly (over a matter of hours)
26DOCUMENTATION FOR UNAVOIDABLE END OF LIFE ULCERS Complete wound closure may not be realistic goal, wound may improve but due to progressive or irreversible underlying medical condition, complete healing is not expected.The wound represents an additional body systems failure for a person who is progressing towards deathPatient has been losing weight despite appropriate nutritional interventionsA treatment plan emphasizing minimizing pain and odor related to the dying processRepeated hospitalizations or ED visits in past 6 months may indicate overall decline or instability*from Clinical Practice Guidelines, American Medical Directors Association, CMS guidelines
27MORE TO IT THAN MEETS THE EYE…. TIP OF THE ICEBERGMORE TO IT THAN MEETS THE EYE….
28MUSCLE RESPONSEMuscle damage is more significant than skin damage because muscle is more sensitive to the effects of ischemiaPressure is highest where the muscle or fascia contacts the boneThe ulcer starts at the bone-soft tissue interface and extends towards the skinAn ulcer is like an iceberg – has a small visible surface with a more extensive unknown base
29“Assess the whole person; not just the hole in the person” “Assess the whole person; not just the hole in the person”. ~ Gary Sibbold
31FRICTION Rubbing 2 surfaces against another Friction without pressure causes damage to only the epidermis and upper dermal layer (think sheet burn)
32SHEAR Friction + Gravity = Shear Think elevation of head of bed and person sliding down in bed or sliding down in reclining chairShear stretches and tears vessels, which reduces the amount of pressure necessary to cause ischemia and deep tissue injuryShearing can cause undermining and tunneling*blisters
33DRYNESS Stratum corneum normally has 10-15% moisture When the moisture drops below 10% skin becomes cracked and fissured, compromising barrier function and increasing susceptibly to injuryLotions/creams that have urea or lactic acid can increase kin surface water-binding capacityBest to apply immediately after bathing when skin is damp because the creams trap moisture under the skin
34MOISTURE 65% Of patients with PrUs are incontinent If a person is incontinent of feces, the chances of getting a PrU increases by 3XContinued exposure causes maceration – tissue softeningExposure to sweat or incontinent brief raises skin pH to 7.1Exposure to urine or stool increases pH to 8+
35Moisture continued… Acid Mantle of the skin – A slightly acidic film of the skin that acts as a barrier to bacteria, viruses and other potential contaminants that might penetrate the skinSkin has a normal pH ofSlightly acidicSweat, urine, stool, some soaps are alkaline and decrease the acidity of the skin making it more prone for skin breakdown and dermatitis
36PERINEAL DERMATITISNot to be confused with Pressure Ulcers (but in the presence of friction, sheer or pressure easier to cause tissue damage)Also called incontinence related dermatitis.Most common cause of nosocomial diarrhea is C-Diff, second is candida albicans (yeast)Regular use of absorptive pads or briefs raises the pH of the skin and increases production of perspiration
38Candida Usually treated topically Remove moisture Kerlix AMD dressings Interdry AG (from Coloplast)Check for other sources of infection – (thrush, vaginitis) which requires oral treatment (diflucan)
39INTRINSIC FACTORS Malnutrition and dehydration Critical illness Age – thinning of the skinLow Blood pressureTissue OxygenationSmokingWeight lossInfectionFever
40PREVENTION Risk assessment Systematic skin assessment Reduction of risk factorsPatient, family and staff education
41RISK ASSESSMENT Braden Scale – 6 subscales that reflect the degrees of sensory perception, moisture, activity, mobility, nutrition, friction and shear.Each subscale is rated on a scale according to risk and the scores are totaledLower scores mean higher risk for pressure ulcer development
42POSITIONINGFor bed bound patients, perform full position change at least every 2 hours.Sage Turn and Position Unit
435 PILLOW RULEPillow 1 under legs to elevate heels (or Prevelon Heel Protectors)Pillow 2 between ankles if on sidePillow 3 between knees if on sidePillow behind the back (unless you are using the Turn and position unit)Pillow 5 under the head
44Do you need to float heels: Can the patient lift their leg off the bed by themselves and hold it a few seconds?
45RULE OF 30Head of bed is elevated no more than 30 degrees and the body is placed in a 30 degree laterally included position when positioned on either side. If the HOB is raised for eating or watching TV, return to original 30 asapIn the 30 degree lateral inclined position, hips and shoulders are tilted to 30 degrees supine position and pillows or foam wedges are used to keep positioned without pressure on the sacrum. Never place directly on trochanter. (Turn and Position Unit)
46MORE Use draw sheet and trapeze if possible to decrease friction Do not position, if possible, over area of break downNEVER massage reddened areas (this is friction and will increase break down)Keep in mind heel pads and elbow pads prevent FRICTION not PRESSURE
47PREVENTION OF FRICTION Lift sheetsTrapezeHeel and elbow padsMoisturizersHydrationTransparent dressingsSkin sealants
48SEATING Instruct patient to self reposition, if able, every 15 minutes If patient is unable to independently reposition, place on pressure redistributing cushion and you reposition every hourCheck for bottoming out
49PREVENTION OF SHEAR Anti-shear mattress Lift sheets HOB 30 degrees Use pillows or wedgesUse Turn and Position System
50HAMMOCK EFFECT Seat sags in the middle. Needs replaced, placing cushion will not correctThighs roll inward, creating pressure on trochantersSpine slouches, body slides forward causing pressure on the ITs, and shear on the buttocks thighs and spine
51Support Surfaces Group 1 static – foam, air, water, gel Group 2 Dynamic – alternating pressure, low air loss, rotationalGroup 3 Air Fluidized (clinitron) – fluidized beds (not for pts with unstable spine or pulmonary disease). Good for pts with multiple PU’s, burns, flaps and grafts
52MANAGEMENT OF INCONTINENCE Bowel and bladder training when appropriatiteLoose stools – ask for bulk in diet, dietary changes, check for c-diffAvoid hot water when cleansingDo not scrubUse skin barriersUse open system for management while in bed and at night
53TREATMENT Remove pressure, friction and sheer Stage I PrUs can be healed in one dayUse of hydrocolloids may be helpful in increasing the healing rate on stage II, III. May be used in stage I if semi transparentStage IV or heavily exudating stage II may need alginate, composites, foams and transparent films.Advanced wound care products (ECM, skin grafting, wound vacs etc)
54NON STERILE DRESSING CHANGE TECHNIQUE Refer to policy VA-76 on the Communicator
55AHRQ (Agency for Healthcare Research)RECOMMENDATIONS NO foam ringsNo cut outsNo DonutsWhy? Pressure and ischemia!
57LABS CONTINUTEDAlbumin – long term measure of protein status (18-21 days)Prealbumin – more current picture of protein status (1-2 days)Transferrin – transports iron to bone marrow. Used to measure visceral protein status. Accurate indicator of protein stores as it responds more readily than albuminTotal Lymphocyte count – measures immunity to proteins (required to elicit immune response necessary to heal)Glucose – elevated glucose impairs wound healing by impairing lymphocyte function and immune responseHematocrit – low red blood cells= anemia= decreased oxygen carrying capacityCBC – complete blood count gives overview of general health status
58MARKERS OF MALNUTRITION MILDMODERATESEVERE% usual body wt85-95%75-84%<75%*Albumin, g/dL<2.1Pre albumin mg/dL10-165-9<5Transferrin, mg/dL<100Total lymphocyte count/mm3<1500<1200<800
59Transferrin vs Ferritin Sick people produce less transferrin, so the body cannot transport iron to bone marrow. If you supplement extra iron to combat anemia, that is converted to ferritin, which leads to higher infection risks.
60Minnesota Starvation Study 1944Showed that serum albumin was not a good predictor of nutritional or protein status
61UNINTENDED WEIGHT LOSS A 5% loss of weight from the previous month indicates a significant decline in nutritional statusA 10% loss in 6 months or less indicates a significant decline in nutritional statusProtein energy malnutrition is the most common form of malnutrition in people with wounds which results in loss of lean body mass (LBI)LBI results in catabolism – breakdown of muscle for energy***NON HEALING WOUNDS!
62NUTRITIONAL NEEDS WITH PrU’s Calorie needs increase from times the basal energy expenditureProtein needs increase from gm/kg body weight. Proteins are made of amino acids are necessary to generate acute phase proteins, including collagen and proteogycansFats are important for development of cell membranesFluid requirements are 30 ml/kg body weight or a minimum of 1500 ml/dayArginine and Glutamine – amino acids responsible for collagan formation cannot be metabolized at adequate rate during stress, therefore must be suplimentedVit A – important for deposition of collagin, and fibroblastsVit C – cofactor in collagen formation and fibroblastVit B – necessary to get energy from amino acidsCopper – required for collagen linking – low = weak scars and frequent break downIron – important for hemoglobin and transport of oxygen
63VITAMINS/MINERALSCopper, Zinc and Iron all compete for the same cell receptor.If you have weak scar tissue or dehisced wounds likely too much zinc and not enough copper which is important for skin integritySupplements with >30 mg zinc = too muchNew studies do not show any benefit from supplemental Vit C, plus it can be bad for kidney stone patients
64COMPLETE VS INCOMPLETE PROTEIN Complete have all 3 amino acidsChicken = completeGround beef and lunch meat = often incompleteTofu = complete*protein is most important at breakfast, because you have all day to absorb it and make it available for use. If not available during the day, body will catabolize itself, and then use protein to replace catabolized tissue. Constant deficit.
65ENCOURAGE BLOOD FLOW Heal through blood flow Exercise: punching, legs kicks, isometrics etc encourage 10X every hourWalking at least 4 times a day if ablePT/OT
66ARE ALL ULCERS PRESSURE ULCERS? NO!Trauma, skin tears, moisture, arterial, venous, diabetic.These are often confused with Pressure ulcers.Pressure Ulcers are over bony prominences as a result of pressure.Do not stage any other ulcer besides pressure ulcers