Description of Ulcers Stage Ulcer Location Size Wound bed Granulation tissue Necrotic tissue Wound edges Drainage Infection Pain
STAGING OF PRESSURE ULCERS Stage I: Persistent nonblanchable erythema of intact skin.
STAGING OF PRESSURE ULCERS Stage II: Partial-thickness skin loss involving epidermis, dermis, or both. Ulcer is superficial and presents as an abrasion, blister, or shallow crater.
STAGING OF PRESSURE ULCERS Stage III: Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
STAGING OF PRESSURE ULCERS Stage IV: Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule). Undermining and sinus tracts may also be present. Used with permission LWW
STAGING OF PRESSURE ULCERS Unstageable: Full thickness tissue loss in which slough (yellow, tan, gray, green or brown), eschar (tan, brown or black), or both in the wound bed cover the base of the ulcer.
Granulation tissue Intermediate step in healing Very fragile Appearance: Shiny red & grainy When inadequate blood flow exists, granulation tissue may pale in color.
Slough non-viable tissue and requires debridement Appearance – stringy mass Color – white, yellow/tan, brown Becomes thicker and harder to remove Easily confused with normal tissues (tendons)
Eschar Dead tissue, Color: – Tan, brown, black Leathery, dry hard Soft, with purulent discharge – Slimy.
Prevention Reposition – at least every 2 hours (may use pillows, foam wedges) Keep head of bed at lowest elevation possible Use lifting devices to decrease friction and shear Remind patients in chairs to shift weight every 15 min “Doughnut” seat cushions are contraindicated, may cause pressure ulcers Pay special attention to heels (heel ulcers account for 20% of all pressure ulcers)
PREVENTING HEEL ULCERS Assess heels of high-risk patients every day Use moisturizer on heels (no massage) twice a day Apply dressings to heels:
PREVENTING HEEL ULCERS Have patients wear: Socks to prevent friction (remove at bedtime) Properly fitting sneakers or shoes when in wheelchair Place pillow under legs to support heels off bed Place heel cushions to prevent pressure Turn patients every 2 hours, repositioning heels
PRESSURE-REDUCING SUPPORT SURFACES **Use for all older persons at risk for ulcers**
Nrs. Dx: Impaired tissue integrity Document Track progress Do not “reverse stage” Ulcers do not replace lost muscle, subcutaneous fat, or dermis before re-epithelializing E.g. Stage IV cannot become stage III
Dressing Keep wound bed moist Keep surrounding tissue clean & dry Do not use antiseptic agents
Types of Dressings Gauze Transparent films Hydrocolloid Hydrogel Alginates Foam Composite
Nrs. Dx: risk for infection Wound cleansing and dressing – frequency when purulent or foul-smelling drainage is first observed – Avoid topical antiseptics because of their tissue toxicity topical antibiotics Cultures
Nrs. Dx: Alt. nutrition, less than body requirements nutritional assessment q day wts Protein Lab – Albumin
MANAGEMENT: SURGICAL REPAIR used for stage III and IV Risks to benefits All wounds with necrotic tissue should be debrided
SUMMARY Older adults are at high risk for development of pressure ulcers Pressure ulcers may result in serious complications Techniques that reduce pressure, moisture, friction, and shear can prevent pressure ulcers Pressure ulcers should be treated with proper cleansing, dressings, debridement, or surgery as indicated