1. Pressure Ulcers JENNIFER POLGLAZE & ASHLEY COUTURIER

2. CAUSE  Pressure on the skin reduces blood flow to the area. Without enough blood, the skin can die. An ulcer may form.

3. Risk Factors  wheelchair or stay in bed for a long time  Are an older adult  Cannot move certain parts of your body without help because of a spine or brain injury or disease such as multiple sclerosis  Have a disease that affects blood flow, including diabetes or vascular disease  Have Alzheimer's disease or another condition that affects your mental status  Have fragile skin  Have urinary incontinence or bowel incontinence  Do not get enough nutrition (malnourishment)

4. Contributing Factors  Sustained Pressure  When your skin and the underlying tissues are trapped between bone and a surface such as a wheelchair or a bed, the pressure may be greater than the pressure of the blood flowing in the tiny vessels (capillaries) that deliver oxygen and other nutrients to tissues. Without these essential nutrients, skin cells and tissues are damaged and may eventually die.  Friction  is the resistance to motion. It may occur when the skin is dragged across a surface, such as when you change position or a care provider moves you. The friction may be even greater if the skin is moist. Friction may make fragile skin more vulnerable to injury.  Shearing  occurs when two surfaces move in the opposite direction. For example, when a hospital bed is elevated at the head, you can slide down in bed. As the tailbone moves down, the skin over the bone may stay in place — essentially pulling in the opposite direction. This motion may injure tissue and blood vessels, making the site more vulnerable to damage from sustained pressure

5. Stages  Stage I: A reddened area on the skin that, when pressed, does not turn white. This is a sign that a pressure ulcer is starting to develop.  Stage II: The skin blisters or forms an open sore. The area around the sore may be red and irritated.  Stage III: The skin now develops an open, sunken hole called a crater. There is damage to the tissue below the skin.  Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes to tendons and joints  Unstageable - Full Thickness, depth unknown  Pressure sores categorized as deep tissue injury may be purple or maroon. This may be an area of skin or blood-filled blister due to damage of soft tissue from pressure. The area around may be sore, firm, mushy, boggy, warmer, or cooler compared with tissue nearby

7. Complications  Infections  Cellulitis  Osteomyelitis  Bacteremia or a bacterial infection in the blood (sepsis)  Necrotizing fasciitis or a bacterial infection  Endocarditis  Meningitis  Septic arthritis  Abscesses  Squamous cell skin cancer

8. Scope of Problem National Statistics3E Unit Population  Stage 2; Healed  Unstageable  Midline, coccyx

9. Implications  Patient  The development of a pressure ulcer can interfere with functional recovery, produce pain and discomfort, promote social isolation, and contribute to excessive length of hospital stay  Institution  Reimbursement  Reputation  Legal  financial implications of pressure ulcers impact our legal system. Lawsuits over pressure ulcers are increasingly more common in both short- and long-term settings and judgments have been reported to be as high as $312 million in a single case  Healthcare Resources  The U.S. Centers for Medicare and Medicaid Services views a pressure ulcer as a “never event” and therefore the development of a pressure ulcer can lead to significant monetary penalties.

11. Recommendations  Admission Assessment ; baseline  Skin inspection daily  High Risk patients- focused examinations daily  Effective communication r/t skin breakdown  Repositioning  Proper skin care; clean and dry, protect form moisture, manage incontinence  Nutrition; possible increase in calories, protein, vitamins and minerals, dietary supp. (Vitamin C and Zinc)  Assistive devices – pressure reducing mattresses and heel floats, Mepilex Silicone Foam Dressing

13. Nursing Assessment  Assess general condition of skin  Specifically assess skin over bony prominences (sacrum, trochanters, scapulae, elbows, heels, inner and outer malleolus, inner and outer knees, back of head)  Assess patient's awareness of the sensation of pressure  Assess patient's ability to move  Assess patient's nutritional status  Assess for fecal and/or urinary incontinence  Assess for environmental moisture (wound drainage, high humidity  Reassess skin often and whenever the patient's condition or treatment plan results in an increased number of risk factors

14. Assessment Tool- Braden Scale

15. Nursing Plan- Impaired Skin Integrity  Regain integrity of skin surface  Report any altered sensation or pain at site of skin impairment  Demonstrate understanding of plan to heal skin and prevent reinjury  Describe measures to protect and heal the skin and to care for any skin lesion

16. Nursing Interventions  Encourage implementation and posting of a turning schedule, restricting time in one position to 2 hours or less and customizing the schedule to patient's routine and caregiver's needs  implementation of pressure-relieving devices  Encourage patient and/or caregiver to maintain functional body alignment  Encourage ambulation if patient is able  Clean, dry, and moisturize skin  Encourage adequate nutrition and hydration

17. Nursing Evaluation  PATIENT WILL BE ABLE TO  Regain integrity of skin surface  Report any altered sensation or pain at site of skin impairment  Demonstrate understanding of plan to heal skin and prevent reinjury  Describe measures to protect and heal the skin and to care for any skin lesion

18. Pressure Ulcer Team 2007 Data  Monthly Pressure Ulcer Committee Meetings  Team  Nurse Quality, RN 4W, Director, Nursing Informatics, Educator  Pressure Ulcer 65-80% “Hospital Acquired” First documentation > 24 hrs. post admission  Feb 11- reviews flow diagram for skin assessment and documentation process  Blodgett April-May 2007  Butterworth March-April 2007

19. Spectrum’s Initiatives  2 RN skin checks within 24 hours of admission  Skin Care Teams- Skin Champion  Monthly hospital checks  Assess  Position  Document  Educate staff and patients

20. Education Materials  Preventing Pressure Ulcers – Brochure  Nurse Educators  KRAMES  Charge nurse

21. References  Klopp, A., Storey, V., & Bronstein, K. (2012). Skin integrity, impaired: risk for pressure sores, pressure ulcers, bed sores; decubitus care. In Elsevier. Retrieved from http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Construct or/gulanick47.html  Ladwig, G. B., & Ackley, B. J. (2014). Mosby's Guide To Nursing Diagnosis (4th ed., pp. 719-722). Maryland Heights, MO: Elsevier.  Mayo Clinic Staff. (2015). Diseases & conditions bedsores (pressure sores). In Mayo Clinic. Retrieved from http://www.mayoclinic.org/diseases- conditions/bedsores/basics/definition/con-20030848  U. S. National Library of Medicine. (2015). Pressure Ulcer. In Medline Plus. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/007071.htm