2. Developed by HELEN HOLDER RN, BSN Alverno College Milwaukee holderhc@alverno.edu PRESSURE ULCER PROGRAM

3. This site was designed with nursing assistants in mind! You’ll learn: What is a pressure ulcer? What is really going on under the skin? What part does nutrition play? What part do you play to keep them away?

4. What should I know after viewing this site? Be able to name layers and functions of the skin.Be able to name layers and functions of the skin. Name those at risk. Explain how pressure ulcers are formed. Become aware of complications from pressure ulcersBecome aware of complications from pressure ulcers Understand the importance of nutrition. Identify the important prevention techniques used by CNA’s.Identify the important prevention techniques used by CNA’s. Printshop2005

5. Why Skin? One of the largest organs in the body Vital for homeostasis Protection Retards water loss Regulates body temperature House of sensory nerves Contains immune system cells Breaks down and uses various chemicals Excretes waste Printshop2005

6. Layer by Layer Skin has three layers Epidermis- Outer most layer- 5 distinct layers Dermis- Middle layer Hypodermis or Subcutaneous Layer

7. EPIDERMIS Lacks blood vessels Cells reproduce & grow and shed as “dry skin” Contains melanocytes for skin color Thickest area of epidermis: palms & soles

8. DERMIS Contains blood vessels Binds epidermis to underlying tissue Contains muscle fibers-arrector pili Nerves scattered through out Contains hair follicles, sebaceous & sweat glands Thickness: 0.5mm eyelids to 3.0mm soles

9. HYPODERMIS Subcutaneous Loose connective tissue & adipose tissue Thickness varies Holds major vessels in place that supply blood to skin Insulates body No definition from dermal layer

10. A function of the skin is? Tan nicely Excrete waste known as diarrhea Regulate the temperature of the body

11. NO Tanning is nice but not necessary for living. Printshop2005

12. NO Skin does excrete waste as a function but it excretes sweat, not diarrhea which is a function of the Gastrointestinal tract Printshop2005

13. HOORAY The skin regulates the temperature of our bodies. To conserve heat, our blood vessels constrict, in turn causing shivering that produces heat. To cool the body, our blood vessels dilate causing blood to carry heat deep in the body to the surface, sweat develops, evaporation occurs, the body cools. Printshop2005

14. Name that layer! Name the layer that contains muscle fiber. Dermis Subcutaneous Epidermis

15. You got it! Arrector pili is the muscle fiber found in the dermis that makes your hair stand up when you are cold or frightened. Printshop2005

16. Try again Subcutaneous or hypodermis layer that holds major vessels for the skin. Printshop2005

17. Better luck next time! Epidermis contains no nerve fiber, but if your looking for dead skin you’ve come to the right place! Printshop2005

18. Genetic Connection NONE Those at risk: people with Peripheral vascular disease Diabetes Paralysis of limbs Casts Obese/Thin Printshop2005

19. Picture This Crowded church, packed pews, no cushions, sermon that goes on forever and no one can move. Once you have positioned yourself you are stuck for the duration. How does it feel on your hips and tailbone? We’re talking real pressure! Now think about how someone with no control over their movements feels. Perfect set up for pressure ulcers! Printshop2005

20. How does that ulcer form? Resident lying in bed on their back. Buttocks, by force of gravity sink into mattress. Soft tissue presses against the bones that don’t go anywhere. Blood vessels are pinched between bone and weight of gravity. Blood flow to soft tissue is cut off. Cell starvation and death occur Pressure ulcer is born.

21. FIRST SIGN IS INFLAMMATION Redness/non-blanching Warmth Swelling Pain Loss of function FOR MORE INFORMATION ON INFLAMMATION: http://www.siumed.edu/~dking2/intro/inflam.htm http://faculty.alverno.edu/bowneps/inflammation/inflammindex.htm Bowne,3/22/2006 Printshop2005

22. Staging 4 levels progression No open area Deep wound Printshop2005

23. Stage I Non-blanching redness Intact skin Precursor to pressure ulcer Sorrentino, S.A., Mosby’s Textbook for Nursing Assistants, 6th Ed., St. Louis: Elsevier; 2004: pg. 587.

24. Stage II Partial thickness skin loss Abrasion Blister Shallow Crater Sorrentino, S.A., Mosby’s Textbook for Nursing Assistants, 6th Ed., St. Louis: Elsevier; 2004: pg. 587.

25. Stage III Full thickness skin loss Not through fat layer Deep crater Damage or Necrosis Sorrentino, S.A., Mosby’s Textbook for Nursing Assistants, 6th Ed., St. Louis: Elsevier; 2004: pg. 587.

26. Stage IV Extensive destruction Necrosis Muscle/Bone damage Tunneling Sorrentino, S.A., Mosby’s Textbook for Nursing Assistants, 6th Ed., St. Louis: Elsevier; 2004: pg. 587.

27. Necrosis ( cell death)

28. What is one of the First Signs of Inflammation ? Blanching Warmth Stress

29. Blanching Inflammation is characterized by redness at the site of tissue injury. If you lightly put your finger on the reddened area and exert slight pressure the area will not “whiten” or blanch. Printshop2005

30. Warmth Correct. Warmth is an indicator of inflammation due to the increased blood flow to the area. Printshop2005

31. Stress Try again. Stress may lead to a different type of ulcer but doesn’t usually lead to a “pressure” ulcer. Printshop2005

32. A characteristic of Stage II is ? Blister Full thickness skin loss Tunneling

33. Yahoo! Blistering is one of the early characteristics of the Stage II pressure ulcer. Printshop2005

34. No Full thickness skin loss happens in the Stage III pressure ulcer. The wound will appear as an open area and necrosis may be visible.

35. Try again Tunneling happens during Stage VI. Wounds will begin to produce deeper pockets as the tissue is eroded away. The pocket may be narrow and proceed to another area of tissue, hence the term “tunnel”. Printshop2005

36. Factors that lead to Pressure Ulcers Malnutrition Low protein intake Inability to feed self Immobility Incontinence urine/feces on skin Printshop2005

37. Warning Signs of Malnutrition Sudden/Recent weight loss Dehydration Decrease appetite Printshop2005

38. What is Needed? Elderly need at least 1200 calories/day Protein- for repair & regrowth Carbohydrates & Fats-Tissue maintenance & energy source Vitamins- promote wound healing Printshop2005

39. Protein Best Sources: eggs milk cheese yogurt Printshop2005

40. Carbohydrates & Fats Carb sources Whole grains Cereal Rice Unsaturated fats Olive oil Canola oil Safflower oil Printshop2005

41. Vitamins Vitamin C- for collagen formation Good Sources: Citrus fruit strawberries Vitamins A & E- for tissue repair Good Sources: orange & green vegetables Vitamin K- for normal blood clotting Good Sources: Green leafy vegetables Printshop2005

42. Name a Symptom of Malnutrition Sudden weight gain Consistently decreased appetite Excessive thirst

43. NO Sudden or recent weight loss is a symptom of malnutrition Printshop2005

44. You’re Right An elderly person that is not consistently eating at least 1200 calories per day, may be headed for the state of malnutrition Printshop2005

45. Check again! Dehydration is a sign of malnutrition. Excessive thirst is a symptom of Diabetes. Printshop2005

46. Good Source of Vitamin C? Green leafy vegetables Liver Strawberries

47. Not this time Vitamin K is found in green leafy vegetables Printshop2005

48. Not Liver Liver is high in iron and cholesterol but not Vitamin C Printshop2005

49. Right you are! Strawberries are a good source of Vitamin C and taste good too! Printshop2005

50. PREVENTION Best protections against pressure ulcers is observation, good skin care,mobility, and good nutrition. CNA’s importance--- -most direct contact with residents Microsoft Office XP2002

51. CNA Role in Nutrition Assist at Mealtime make it social and take your time feeding the resident. Give supplements as required. Ensure or 2Cal or whatever other supplement is ordered. Substitute food dislikes for preference. Report & Record appropriately. Microsoft OfficeXP2002

52. CNA Role in Immobility Reduce pressure: Turn bed residents every 2 hours. Even a 15 degree turn helps to relieve pressure on skin surface. Use a written turning schedule so that others know in which direction the resident is to go. Microsoft OfficeXP2002

53. Positioning Position correctly! Use pillows to support joints Avoid skin touching skin Check to make sure no body part is hitting a wall or railing Remember! Check positioning in the chairs. Chairs too small or residents that lean to one side may have pressure. Microsoft OfficeXP2002

54. Keep Resident Moving!! Printshop2005

55. Shearing & Friction Shearing- Skin layers slide in different directions Friction- causes a rug burn on skin Microsoft OfficeXP2002

56. Avoid Shearing & Friction Use lifter sheet to move resident up in bed Use assistance of over bed trapeze Keep HOB 30 degrees or lower to avoid slipping down in bed Cup heels & elbows during ROM exercises Don’t drag heels over sheets when using lifts. PrintShop2005

57. Importance of Skin Care Check every 2 hours for incontinence. Feces, urine and even soap are abrasive to the skin due to a ph imbalance. PrintShop 2005

58. Clean, Rinse and thoroughly Dry skin after each incontinent episode. PrintShop2005

59. Moisturize skin with lotion to prevent dry skin. Use lotion over bony prominences but do not massage reddened areas as it may cause more damage to underlying tissue Use special barrier creams as ordered Microsoft OutlookXP2002

60. To avoid a shearing incident the CNA should ……..? Elevate the HOB 45 degrees Use a lifter sheet Support the head during ROM

61. Too High! Never raise the HOB over 30 degrees when a resident is confined to bed. Anything over 30 degrees may cause a shearing incident! Microsoft OfficeXP2002

62. YEAH!!! Use the lifter sheet to move resident more easily and saves your back too! Microsoft OfficeXP2002

63. Not this head! When doing ROM you want to protect the heels and elbows from dragging across the sheets and causing a friction burn. Microsoft OfficeXP2002

64. How often do you turn a bed ridden resident? Every 30 minutes Every 4 hours Every 2 hours

65. That’s Lunch! This is the time allotment for your lunch. It is important that you take care of yourself and don’t skip that part of your day! Microsoft OfficeXP2002

66. TPR Temperature, Pulse, and Respirations are usually done every 4 hours on residents that may be ill. For the bedridden resident, this is far too long to lay in one position! Microsoft OfficeXP2002

67. YES! Remember to turn your bedridden resident every 2 hours to prevent pressure ulcers. Microsoft OfficeXP2002

68. You never have to worry about residents that sit in wheelchairs. TRUE FALSE

69. Wrong! Residents don’t always sit nor are they always positioned in the wheelchair correctly. Take a minute to make sure there are no areas rubbing or resting against hardware on the wheelchair. Microsoft OfficeXP2002

70. Correct You must have checked your resident after you positioned them. Obviously there are no areas pressed against the hardware of the wheelchair! Microsoft OfficeXP2002

71. BEST PREVENTION Superior Care! Keen Observation! Prompt Reporting! PrintShop2005

72. References Slide 5- Shier, D., Butler, J., & Lewis, R., 1996. Hole’s anatomy & physiology, 8 th Ed., McGraw-Hill; pg. 171. Slides 22-25- Sorrentino, S.A., 2004. Mosby’s Textbook for Nursing Assistants, 6 th Ed., St. Louis: Elsevier; pg. 587. Slide 20- Bowne, P.,2004. Inflammation Tutorial. Retrieved on March 22, 2006 from the World Wide Web at http://facultyalverno.edu/bowneps/inflammation/inflammindex.htm http://facultyalverno.edu/bowneps/inflammation/inflammindex.htm Slide 20- King, D., 2006. Southern Iowa University. Personal communication.