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Denise Gutwein, MSN, RN, CCRN ICU Clinical Coordinator Putnam Community Medical Center.

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Presentation on theme: "Denise Gutwein, MSN, RN, CCRN ICU Clinical Coordinator Putnam Community Medical Center."— Presentation transcript:

1 Denise Gutwein, MSN, RN, CCRN ICU Clinical Coordinator Putnam Community Medical Center

2 Educational Objectives The learner will be able to: Describe the best approach to prevention Identify the major risk factors for developing pressure ulcers Demonstrate how to use the Braden Scale assessment tool Select the proper surface for assessment findings Give an overview of wound care utilizing dressings, irrigation, debridement and/or wound vac appropriate to the characteristics of the pressure ulcer.

3 Largest organ of the body Covers approximately 3000 square inches Receives 1/3 circulating blood volume From birth to maturity, the skin will undergo a sevenfold expansion Weighs about 6 pounds 1cm of skin has 15 sebaceous glands, 3 yards of blood vessels, 100 sweat glands, 3,000 sensory cells, 4 yards of nerves, 300,000 epidermal cells and 10 hair follicles Is capable of self-generation Can withstand limited mechanical and chemical assault

4 Early Pressure Relief: “I myself think that a few, very small pillows... placed here and there and moved about whenever there seems to be pressure are really preferable...” Florence Nightingale (letter to family with bed-bound child)

5

6 What is a Pressure Ulcer ? Any lesion caused by unrelieved pressure usually over a bony prominence that results in damage to underlying tissue

7 Pressure Ulcer 7 Begins with unrelieved pressure resulting in damage of underlying tissue. U.S. Department of Health and Human Services Agency for Healthcare Research and Policy

8 BEST TREATMENT OPTION

9 Risk Factors Risk Factors for Pressure Ulcer Development: 1.Inability to perceive pressure 2.Incontinence/moisture 3.Decreased activity level 4.Inability to reposition 5.Poor nutritional intake 6.Friction and shear 9

10 Etiology Factors Contributing to Pressure Ulcers Etiologic factors contributing to pressure ulcer occurrence: 1.Pressure 2.Shear 3.Friction 10 FRICTION: Mechanical force that opposes the movement of one surface across another. SHEAR: Shearing forces stretch or tear the blood vessels, reducing the amount of pressure needed to occlude them. PRESSURE: Squeezing together of soft tissue caused by weight

11 Factors affecting Tissue Tolerance Tissue tolerance factors affecting pressure ulcer development: 1. Vascular competency 2. Glycemic control in diabetes mellitus 3. Body weight/malnutrition 4. Age 11

12 FORCES IN PRESSURE ULCER DEVELOPMENT EXTRINSIC PRESSURE SHEAR FRICTION MACERATION TEMPERATURE ERGONOMICS 12 INTRINSIC NUTRITION TISSUE OXYGENATION COMORBIDTIES INFECTION

13 Risk Assessments Using Valid and Reliable Tool The risk assessment tool selected for LifePoint Hospital’s adult patient population is the Braden Scale 1.Score the risk assessment Braden Scale 2.Interpret the significance of the score (high, moderate or low risk levels) 3.Reassess at frequency defined in policy and with significant changes or transfer to another department (to surgery, for example) 13

14 Braden Risk Assessment Scale Braden Risk Assessment Scale (abridged version) Sensory Perception 1 Completely limited2 Very limited3 Slightly limited4 No impairment Moisture 1 Constantly moist2 Very moist3 Occasionally moist 4 No impairment Activity 1 Bedfast2 Chairfast3 Walks Occasionally 4 Walks frequently Mobility 1 Completely immobile2 Very limited3 Slightly limited4 No limitation Nutrition 1 Very poor2 Probably inadequate 3 Adequate4 Excellent Friction and Shear 1 Problem2 Potential problem3 No apparent problem 14

15 Base the Plan on Patient Needs (subscale scores) 15 1.Immobile = reposition q 2 hrs in bed 2.Inactive = reposition q 1hr in w/c 3.Incontinent = protect skin from exposure 4.Malnourished = supplement oral intake 5.Shearing = keep HOB as low as possible 6.Limited awareness= assess skin daily

16 Nutritional Screening 1.Screen for Nutritional Deficits 2.Provide nutritional support to patients with nutritional risks & pressure ulcer risks Complete nutritional assessment by the dietician as indicated Estimation of nutritional requirements Compare nutrient intake with estimated requirements Identify best feeding route Provide nutritional supplements as orders between regular meals in order NOT to influence normal food and fluid intake during regular mealtimes. Monitor nutritional outcome Reassess nutrition status when there is a change in the individual’s condition. 16

17 Conduct a Thorough Skin Assessment Skin Assessment: 1.Assess on admission and routinely (Braden Scale or as per P&P) 2.Document finding and incorporate into plan of care 3.Assess bony prominences and other areas of exposure to etiologic factors. (Roll patient over to inspect front and back) 4.Observable indications of tissue ischemia (defined in stages) 17

18 Pressure ulcer stages Stage 1: epidermis; non-blanching erythema Stage 2: epidermis/dermis; shallow opening; blisters Stage 3: subcutaneous tissue/fascia Stage 4: fascia + bone, tendon, muscle, cartilage Unstageable Note: stages define level of tissue injury and NOT progression of ulcer development or healing.

19 The Medical History & Physical Exam 1.History and Physical Exam findings may lead to the diagnosis of pressure ulcer. 2.The etiology of a wound establishes the type of wound and it’s management. Not all wounds are pressure ulcers 3.While staging may be performed by other clinicians, the stage documented and determined by the physician constitutes the diagnosis. Assure staging documented by various clinicians is not contrary to the stage documented by the physician. The physician is responsible to examine the patient and stage the pressure ulcer. While clinicians may collaborate, the physical exam findings and staging is the responsibility of the physician. 19

20 Physiological condition affecting nutrition Nutritional Care 20 Evaluate appropriate lab data –Albumin normal adult range: mg/dl –Pre-albumin normal adult range: 16 – 42 mg/dl –Hemoglobin normal adult (Female) range: mg/dl normal adult (Male) range: 14 – 18 mg/dl –Hematocrit normal adult (Female) range: 37 – 47% normal adult (Male) range 40 – 54%

21 Documentation Documentation should reflect: 1.Assessment and screening findings History & physical exam findings, reason for hospitalization, lab & other test results, weight and recent change, nutritional screening results, Braden’s score, stage of decubitus, prior treatment and results. 2.Description of skin breakdown to include Location, size in length and width, depth & tissue identified at base of ulcer, exudate, smell, color, firmness/bogginess, tunneling, skin condition at integuma, presence of excar. 3.Reassessment findings at frequency defined in P&P 4.Plan of Care: cleansing, positioning, turning, barrier meds, surface chosen for offloading, dressing care/change, other interventions 5.Interventions as instituted and patient response. 6.Patient/family education 7.Consults 8.Reports to MD with orders received 21

22 Back to the Basics ALL PATIENTS WILL BE KEPT CLEAN & DRY Moisture from incontinence contributes to pressure ulcer development by macerating the skin. Fecal incontinence is a greater risk factor for pressure ulcer development than urinary incontinence because the stool contains bacteria and enzymes that are caustic to the skin. 22

23 Preventive Skin Care 23 Reduce exposure to irritants –Clean immediately after incontinence –Apply skin protectants –Keep linens clean/wrinkle free –Check fit of braces, splints, medical devices (e.g., oxygen tubing, NG tube, stockings) and skin underneath –Maintain environmental humidity Individualize frequency Document

24 Positioning Devices Teach individual to reposition using the trapeze Use lifting devices to move individuals who cannot assist Place pillows/wedges between knees and ankles 24

25 Head of Bed Elevation Maintain lowest possible elevation Avoid more than 30° head- of-bed elevation unless medically needed 25

26 Side Lying Position 26 Avoid positioning directly on the trochanters Use the 30° lateral inclined position

27 Elevate Heels Ensure space between bed and heels (float heels) Use pillows to elevate heels off the bed surface Avoid hyper-extension of the knees Check for injury from splints when used for heel elevation 27

28 No Donuts 28 X Do NOT use plastic rings or donuts for pressure relief as this can cause larger area of tissue injury because of intense pressure along the donut

29 No Massage Avoid Massage of Red Areas 29 Massage may decrease rather than increase blood flow

30 Let the skin breathe Incontinence Management 30 DO: Use gentle soap or skin cleanser Apply topical barrier to protect skin DON’T Scrub the skin Use plastic incontinence pads on low air loss beds

31 Reduce Shear & Shearing Reduce Shear 31 Shear diminishes blood supply to skin Use positioning, transferring & turning techniques to minimize friction/shear injury

32 Support Surfaces Patients at high risk for the development of a pressure ulcer or those with existing pressure ulcer will need a support surface. 32

33 Change Support Surfaces Most pressure reducing devices are more effective than standard hospital mattress 33

34 Types of Support Surfaces Category 1 – Static overlays and mattresses Foam, air, gel Category 2 – Alternating pressure and air flotation Category 3 – Air fluidized – Low air loss bed/mattress 34

35 Support Surfaces in Chairs If patient spends a prolonged time in a wheelchair: – Use pressure reducing cushion – Instruct to also relieve pressure with hand – Lifts if possible every 15 minutes – Change chair to tilt/recline for more pressure distribution 35

36 Assessing Performance of a Support Surface Bottoming out – Surface totally compressed – Use hand check, should not be able to feel person Memory in foam – Shape remains Bunching in gels Deflation in air filled or leakage of fluid or gel 36

37 Hand-off communication Communication to the nurse of new findings is important to discuss in a timely manner. New areas of redness, maceration or breakdown Change in incontinence pattern or diarrhea Odor to wound Dressing soilage or drainage through dressing Temperature, low blood pressure and/or lethargic as a sign of infection Change of shift hand-off communication: Status of skin New areas of redness or breakdown Last turn position Changes in the patient condition Location of decubitus and treatment intervention applied Pain, temperature, vs abnormalities and lethargy

38 Documentation THERE MUST BE DOCUMENTATION THAT WE MADE EVERY ATTEMPT TO PREVENT THE PATIENT FROM DEVELOPING A PRESSURE ULCER. THERE MUST BE DOCUMENTATION THAT WE COMMUNICATE SKIN CARE ISSUES BETWEEN CAREGIVERS THERE MUST BE DOCUMENTATION THAT WE NOTIFY THE PHYSICIAN OF PATIENTS SKIN ASSESSMENT FINDINGS AND WE RECEIVE ORDERS FOR ANY CARE WE PROVIDE TO THE PATIENT

39 PREVENTION OF MACERATION KEEP PATIENTS DRY AND CLEAN DO NOT USE DIAPERS UNLESS THE FAMILY INSISTS. THIS MUST BE DOCUMENTED. USE CLOTH CHUX USE PH BALANCED PERINEAL CLEANSER NOTIFY NURSE TO GET AN ORDER FOR INCONTINENT BARRIER CREAM (CALMOSEPTINE) MAKE ALL EFFORTS TO CONTINUE HOME BOWEL AND BLADDER PROGRAM 39

40 PRESSURE ULCER DUE TO MACERATION 40

41 STAGING

42 Pressure Ulcer Staging Stage I

43 Pressure Ulcer Staging Stage I Dark Skin

44 Pressure Ulcer Staging Stage II Stage 2: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.

45 Pressure Ulcer Staging Stage II

46 Pressure Ulcer Staging Stage II

47 Pressure Ulcer Staging Stage II

48 Pressure Ulcer Staging Stage II

49 Pressure Ulcer Staging Stage III Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

50 Pressure Ulcer Staging Stage III

51 Pressure Ulcer Staging Stage III

52 Pressure Ulcer Staging Stage IV Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (ie., tendon, joint, capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers

53 Pressure Ulcer Staging Stage IV

54 Pressure Ulcer Staging Stage IV

55 Pressure Ulcer Staging Stage IV

56 Pressure Ulcer Staging Stage IV

57 UNSTAGEABLE Pressure Ulcer Staging

58 Venous Ulcers Due to venous insufficiency Medial Aspect of the leg Beefy Red Jagged Painless Treat with compression

59 Venous Ulcers

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61 Diabetic Ulcer

62 SKIN TEARS

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65 Remember... Even on a rough day, someone is having a day that is worse!

66 THE END


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