Pressure Ulcers 101 Pressure ulcer: Any lesion caused by unrelieved pressure that results in damage to the underlying tissue (National Pressure Ulcer Advisory Panel) Small amount of pressure over long period is just as damaging as large amount over short period.
Causes Friction-Visible on skin surface; two surfaces move against each other Shear-Injury beneath skin surface; patient’s skin moves one way, bed sheets move opposite when moving patient
Vulnerable Areas Most common sites in adults: sacrum/coccyx and heels Most common sites in children not paralyzed: back of the head (occiput) But the area over any bony prominence is vulnerable
Theories How do pressure ulcers develop? Theory one: Pressure ulcers begin at the bone and move outward. Theory two: Pressure ulcers start from the skin and work inward
Prevention is Key Which patients are at risk? mobility deficit incontinence inadequate nutrition skin abnormalities increased age light skin pigment diabetes stroke hypotension
Identifying At-Risk Patients Agency for Health Care Research & Quality recommends two tools: Braden Scale-Most widely used; focuses on intensity/duration of pressure & tissue tolerance for pressure; Norton Scale-Developed in United Kingdom; also used, but not as often
JCAHO JCAHO 2006 national patient safety goal for long-term care: prevention of health care-associated pressure ulcers Predict, prevent, and provide early treatment: identify at-risk individuals protect patient from injury reduce pressure ulcers via education
Assessment Recommendations Acute care-On admission & every hours, or when patient condition changes Long-term care-On admission, then weekly for first 4 weeks, monthly to quarterly after that, & when patient condition changes Home health care-On admission & every visit
Interventions Manage moisture Individualize bathing frequency Use a mild soap Don’t rub skin, pat dry Use moisture barrier on skin, incontinence products that pull moisture away from skin
Interventions Manage nutrition Consult dietitian to correct diet deficits Ensure adequate intake of calories, protein, vitamin C, and zinc
Interventions Manage mobility Elevate HOB no more than 30 degrees Use lift devices to prevent friction/shear Protect elbows, heels, sacrum Turn patients frequently PT consult to aid patient in mobility Specialty beds/mattresses for high risk patients
Pressure Ulcer Staging Staging system developed by National Pressure Ulcer Advisory Panel Stages I through IV; see Can’t stage a pressure ulcer until the deepest viable tissue layer is visible
Documenting Pressure Ulcers Location of pressure ulcer Size (length & width) Stage (indicates depth/damage) Presence of sinus tracts Amount/color/consistency/odor of exudate Presence/absence of necrotic tissue Presence/absence epithelialization
Types of Debridement Sharp/surgical-Use of scalpel, scissors, forceps to remove dead tissue; performed by physician and specially trained nurse or therapist Mechanical-Use of force to remove dead tissue (wet-to-dry dressings, irrigation) Autolytic-Cover wound with dressing (films, occlusive, transparent) and allow body’s natural wound fluids to loosen dead tissue Enzymatic-Enzyme applied to wound to remove dead tissue (papain-urea, collagenase)
Last Words Dressings should be individualized! Pain should be assessed & adequately managed! Don’t massage bony prominences, use doughnut-type devices, or allow skin to become dried out!