Pressure Ulcer Prevention and Management Dipti Jethani RN BSN Alverno College All motion clips/images not labeled obtained from Microsoft Clip Art

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Table of Contents Navigation Objectives Incidence Risk Factors Stages of Ulcers Prevention Pathophysiology Complications Treatment

Learning Objectives Learner will be able to identify the stages of pressure ulcers Learner will be able to identify patients at risk for pressure ulcers Learner will be able to identify 3 ways to decrease risk and incidence of pressure ulcers Learner will be able to identify 3 complications of pressure ulcers

Let’s Start With A Case Study Grace is an 84 year old female who was recently admitted into the hospital with a diagnosis of Pneumonia. She has been weak, she used a cane before admittance in the hospital. She now is only mobile per wheel chair. She also is an uncontrolled Type II Diabetic (Non-Insulin Dependent) HOW WILL YOU PREVENT HER FROM DEVELOPING PRESSURE ULCERS? Doheny, Patrick. (2007). Happy planet one. [Photograph]. Retrieved from http://www.flickr.com/photos/14132971@N05/1449122304/.

What Factor Most Puts Grace at Risk for Pressure Ulcers? Age Lack of Mobility Diabetes Having Pneumonia Having a cane – she’ll beat the nurses up! Click Here To Read Case Study Narrative

THAT’ S RIGHT

SORRY TRY AGAIN Although this is a good answer, there is another answer more fitting than this one, try again.

THE SKIN Three Layers Epidermis Dermis Subcutaneous Tissue Outermost Layer Contains sensory receptors for pain, temp, touch, vibration, and pressure detection Barrier to preserve moisture, vitamins, minerals, and proteins Dermis Lies beneath the epidermis, deeper and thicker too Contains connective tissue, & sebaceous glands Contains fat &sweat glands Subcutaneous Tissue Layer of fat and connective tissue Layer of insulation to conserve body heat National Pressure Ulcer Advisory Panel (2007). For Educational Purposes. Lippincott Williams and Wilkins, 2011

Let’s Review… What are pressure ulcers?? Also known as: Pressure/Bed Sores Areas of cellular necrosis and skin breakdown most common over bony prominences Can occur anywhere on the body Most Common Sites: Sacrum, Heels http://www.nlm.nih.gov/medlineplus/ency/imagepages/19091.htm For Educational Purposes, NIH Lippincott Williams and Wilkins, 2011

Incidence of Pressure Ulcers Estimated: 1 mill/yr; annual cost = $1.6 billion The elderly account for > 60% of decubitus patients Since 2008, hospitals are not able to be reimbursed for the care of Stage III or IV pressure ulcers that the patient acquires during their hospital stay 63% increase in hospitalized patients with pressure ulcers between 1993 and 2003 There has been no sig decrease in pressure ulcers in the last 10 years Most often seen in elderly Bedridden; Chair Bound 9 out of 10 patients were covered by a government program (Medicare or Medicaid) In 2007, CMS reported 257,412 cases of preventable pressure ulcers as secondary diagnoses Anders, 2010; Sage Products Inc (2003) Mereck Manual of Geriatrics, 2000; Krasner (2008).

Risk Factors Extrinsic Factors Intrinsic Factors Pressure Friction Shearing Intrinsic Factors Immobility Inactivity Incontinence Malnutrition Age Mental Status Mereck Manual of Geriatrics, 2000

Assessing the Risk BEGINS ON ADMISSION Skin Exam On admission and every shift History of Pressure ulcers Recent weight loss Mobility Status Urinary/Bowel Incontinence Dietary Intake/Nutr Status Use Scales For Assessment Braden Scale Norton Scale PUSH Tool Guren, D., 2010.

Braden Scale Used to accurately predict who will develop pressure ulcers 6 Areas of Assessment: Sensory Perception, Activity, Mobility, Skin Moisture, Nutritional Intake, Friction and Shear Scored from 1-4 1 for low level of functioning and 4 for the highest level or no impairment Total scores range from 6-23 At Risk (15-18) Moderate Risk (13-14) High Risk (10-12) Very High Risk (9 or below) Cassell, 2009.

http://www.bradenscale.com/images/bradenscale.pdf

Prevention BEGINS AT FIRST CONTACT Turn patient at least every 2 hours Do not place pts in a 90 degree lateral position Puts more pressure on greater trochanter and lateral malleolus Don’t elevate HOB > 30 degrees (except when eating) to minimize shearing forces Avoid Fluorescent Light, it casts a blue tint to skin (Capezuti, 2008) Check skin of high risk patients for changes in: Color, turgor, temp, and sensation. Mereck Manual of Geriatrics, 2000

Prevention Cont. Patient should not sit more than 2 hours Sitting position puts increased pressure on ischial tuberosities. Reposition patient every hour in chair Teach patient to shift weight every 15 minutes Do not use pillows/ rubber doughnuts Keep skin surface clean and dry (Meticulous skin care) As few pads as possible should be used Main Points: Keep pressure off the area of breakdown Clean and dress the wound Maintain good nutrition Mereck Manual of Geriatrics, 2000

Prevention Monitor Lab Values: HgB <12 Total Lymphocyte Count <1200 Serum Albumin <3.5 Serum Transferrin <170 Promote Movement and Freq Position Changes Mereck Manual of Geriatrics, 2000 (Anders, 2010)

Pressure Relief Aids Lippincott Williams and Wilkins, 2011 Gel Flotation Pads Sheep Skin Heel Boots Low Air Loss Bed Air-Fluidized Bed Spanco Mattress Convoluted Foam Mattress Alternating Pressure Mattress Lippincott Williams and Wilkins, 2011

Pressure Points Most Develop Over 5 locations: 90% occur in lower body Sacral Area Greater Trochanter Ischial Tuberosity Heels Lateral Malleolus 90% occur in lower body Agency for Health Care Policy and Research (2008) Lippincott Williams and Wilkins, 2011; Abrass, 2004

Case Study Grace has a history of COPD and has smoked 1 PPD for 22 years, but quit 7 years ago. Her Diabetes has progressed and due to complications her Left foot was amputated. On the last shift a small Stage I pressure ulcer was also discovered.

What complication should the nurse most focus on preventing? A. Progression of the Ulcer to a new stage B. Increased Length of Stay C. Infection D. Sepsis E. All of the Above F. A and B only Click Here To Read Case Study Narrative

Stages of Pressure Ulcers Staged according to depth of damage Bright Hub Inc, 2011. Public Domain Image Mereck Manual of Geriatrics, 2000

Suspected Deep Tissue Injury Maroon or purple intact skin or a blood filled blister Cause: shearing or pressure on the underlying soft tissue Before discoloration occurs, the area may be: Painful Mushy, firm, or boggy Warmer or cooler as compared to other tissue National Pressure Ulcer Advisory Panel (2007). For Educational Purposes. Abrass, 2004

Stage I An area of intact skin that does not blanch and is usually over a bony prominence. NON-BLANCHABLE Darkly pigmented skin may not show blanching but its color may differ from the surrounding area. The area may be painful, firm or soft, or warmer or cooler when compared to the surrounding tissue. National Pressure Ulcer Advisory Panel (2007). For Educational Purposes. Abrass, 2004

Stage II A superficial partial thickness wound Presents as a shallow, open ulcer without slough and with a red and pink wound bed. This term shouldn’t be used to describe: Perineal dermatitis, maceration, tape burns, skin tears or excoriation . Only use to describe An abrasion, a blister, or a shallow crater that involves the epidermis and dermis. National Pressure Ulcer Advisory Panel (2007). For Educational Purposes. Abrass, 2004

Stage III A full-thickness wound with tissue loss. The subcutaneous tissue may be visible but muscle, tendon, or bone is not exposed. Slough may be present but it does not hide the depth of the tissue loss. Undermining and tunneling may be present. Bone/Tendon are NOT visible National Pressure Ulcer Advisory Panel (2007). For Educational Purposes. Abrass, 2004; NPUAP, 2007

Stage IV Involves Full-Thickness skin loss Can visibly see exposed muscle, bone, or tendon Eschar and sloughing may be present as well as undermining and tunneling National Pressure Ulcer Advisory Panel (2007). For Educational Purposes. Abrass, 2004

Unstageable Involves full-thickness tissue loss. The base of the ulcer is covered by : Slough: yellow, tan, gray, green, or brown OR Eschar: tan, brown, or black The pressure ulcer cannot be staged until enough eschar or slough is removed to expose the base of the wound National Pressure Ulcer Advisory Panel (2007). For Educational Purposes. Abrass, 2004

Definitions Friction: Surface damage caused by skin rubbing against another surface. Shearing: Trauma to skin caused by tissue layers sliding against each other, results in disruption of blood vessels. Maceration: Softening of tissue by soaking in fluids. Debridement: Removal of damaged tissue. Eschar: Thick, leathery necrotic tissue; damaged tissue. Slough: Loose, stringy necrotic tissue Undermining: Tissue destruction underlying intact skin along wound edges. Tunneling: A narrow channel/passageway extending into healthy tissue. Oklahoma Foundation for Medical Quality, 2009

Case Study Cont. Which of the following is Grace most at risk for? Friction Shearing Maceration Laceration Click Here To Read Case Study Narrative

Case Study Grace became incontinent of bowel and bladder. Click Here To Read Case Study Narrative Grace became incontinent of bowel and bladder. She has a decreased appetite and has become more confused since the last shift. A urine specimen was obtained and results show she has a UTI.

What measures can you take to prevent progression and development of pressure ulcers?

Pathophysiology Affected area becomes hypoxic and ischemic d/t press exerted on it  Decreased blood flow to site Capillaries Collapse, Thrombosis occurs Tissue Edema/Necrosis Accumulation of waste products at site Tissue Breakdown Cell Death Lippincott Williams and Wilkins, 2011

Stress Response and Pressure Ulcers Stress occurs  Adrenal Glands produce Epi SNS releases NE NE causes peripheral vasoconstriction Decreased Oxygen Delivery Epi enhances production of chalone Chalone protein depresses regeneration of epidermal tissue Tissue Breakdown Cell Death Epi = Epinephrine NE = Norepinephrine Place mouse over chalone to see definition Maklebust, J., & Sieggreen, M. (2001).

Aging Muscle & fat are lost with aging (to spread out press) Skin Elasticity Decreases  in ascorbic acid levels: BVs & Connective tx more fragile Lowers threshold of pressure injury  in # of Dermal BVs: Incr risk of ischemic injury by press and shearing forces Wound healing ed: Repair rate declines Cell proliferation es Wound tensile strength es Collagen deposition es Lippincott Williams and Wilkins, 2011; Mereck Manual of Geriatrics, 2000

Inflammation Damaged BVs  Exposed Collagen With Thrombin exposed collagen stimulates platelet activity Activation, aggregation, and adhesion of platelets and release mediators Stimulates Vasoactive substances Breakdown products attract nuetrophils and macrophages Monocytes become Macrophages Release growth factors Trigger Fibroblasts to secrete collagen & proteins Wound becomes beefy red and bleeds Vasculature begins to restore Hulse, 2011

Genetics Study by Bregstorm & Braden (2002) Certain Medical Conditions found A.A. lowest risk for Stage I ulcers & Caucasians at highest risk for developing Stage I ulcer For stages II-IV AA most at risk for progression of an ulcer & Caucasians least at risk Certain Medical Conditions Diabetes M. Peripheral Vascular Dx Predisposed to developing pressure sores Capezuti, 2008 Mereck Manual of Geriatrics, 2000

Pressure Ulcers on Heels Account for 20% of all pressure ulcers Easy to acquire hard to heal Pressure relief Pillows (floating) Heel Protector Boots Dressing if necessary Foam Pads Guren, D., 2010.

Complications Progression of pressure ulcer Secondary Infections Ex. Sepsis, Cellulitis Osteomyelitis Loss of limb from bone involvement Marjolin’s Ulcer Squamous cell carcinoma within the ulcer Increased Length of Stay Increased Costs Death Lippincott Williams and Wilkins, 2011 Mereck Manual of Geriatrics, 2000; Capezuti, 2008

Treatment Encourage movement Prevention Strategies Pressure Reduction Avoiding Friction/ Shearing Forces Stage III/IV Debridement of necrotic tissue Freq Irrigation (2-3x/d) Dressing of the wound Encourage movement Abrass, 2004; Anders, 2010

POP QUIZ Identify the pressure ulcer stage of the following area of skin abnormality . Public Domain Image obtained from: http://i.ytimg.com/vi/QvcjH98ipeU/2.jpg

IF YOU SAID: STAGE III YOU WERE RIGHT!!

Nutrition Need adequate intake for wound healing and immune response Incr protein/caloric intake Supplement with multi-vitamins (A & C) Consult with a Dietician Loss of > 15% of lean body mass interferes with wound healing Immune Function Loss => Incr risk of infection and decr wound healing Anders, 2010; Maklebust, J., 2001

Nursing Implications Krasner, 2008 Diligent assessment and documentation of the condition of the skin of all patients Use of supplements and feeding assistance devices as needed ONLY pressure ulcers should be st aged; Wounds of other etiologies: (venous insufficiency, arterial, diabetic/neuropathic foot ulcers, trauma, etc) should be described as partial or full thickness or other appropriate system of documentation Pressure ulcers are not staged in a reverse manner Ex. A Stage IV does not progress to a Stage III, II or I. The stage remains the same throughout the healing process. In deeper stages (Stage III and IV) tissue destroyed is replaced by granulation tissue and ultimately scar Krasner, 2008

Documentation Location Size Dressing Type of irrigation soln, drsg applied Drainage Amt, color, odor Undermining/Tunneling Present Infection s/s Character of wound Presence of slough, granulation tissue, etc Pressure relieving measures used Hill Rom Services Inc., 2007

CASE STUDY CONT. What aspect of Grace’s existing condition is the most influencing factor for increasing her risk for pressure ulcers? Pneumonia/COPD Diabetes Venous Insufficiency Lack of Mobility None of the Above All of the Above Click Here To Read Case Study Narrative

Case Study Conclusions Press ulcers can increase morbidity and risk for complications Grace represents a typical patient Documentation and thorough assessment is a necessity FOR A VIRTUAL TOUR OF SKIN BREAKDOWN SEE NEXT SLIDE Doheny, Patrick. (2007). Happy planet one. [Photograph]. Retrieved from http://www.flickr.com/photos/14132971@N05/ 1449122304/.

http://www. youtube. com/watch http://www.youtube.com/watch?v=Eyuguc7KKC4&feature=player_embedded#at=61 (Click here to see video)

Did you meet the objectives?? Identify the stages of pressure ulcers Identify patients at risk for pressure ulcers Identify 3 ways to decrease risk and incidence of pressure ulcers (prevention) Identify 3 complications of pressure ulcers Click the link if you want to review!

TRY AND RUN WITH IT Questions? Email jethandr@alverno.edu

References Abrass, I., Kane, R., Ouslander, J. (2004). Essentials of Clinical Geriatrics. (5th ed.). McGraw Hill-Companies, Inc.Hightstown, NJ. Agency for Health Care Policy and Research (2008). AHCPR Supported Guide and Guidelines [Internet]. Rockville: MD. Retrieved on April 2, 2011 from http://www.ncbi.nlm.nih.gov/books/NBK17977/. Anders, J., Heinemann, A., Leffmann, C., Leutenegger, M., Profener, F., & Von-Rentein-Kruse, W. (2010). Decubitus Ulcers: Pathophysiology and Primary Prevention. Deutsches Arzteblatt International, 107 (21): 371-82. Aurora Health Care (2010). Skin Integrity Alterations Potential/Actual for Adult Inpatients. Milwaukee, WI: Aurora HealthCare. Bright Hub Inc. (2011). Healing Bedsores. Retrieved on April 2, 2011 from http://www.brighthub.com/health/alternativemedicine/articles/52007. aspx. Capezuti, E., Fulmer, T., Mezey, M., & Zwicker, D. (2003). Evidenced Based Geriatric Nursing Protocols For Best Practice. (3rd ed). Springer Publishing Co., New York, NY. Cassell, C. (2009). Pressure Ulcer Assessment: The Braden Scale for Predicting Pressure Ulcer Sore Risk. Health Services Advisory Group. Guren, D. (2010). Skin is in: positioning your surgical patient matters. Retrieved March 28, 2011 from http://uwcne.net/grandrounds/display.asp?ID=48& submit=Video.

References Cont Hill-Rom Services Inc. (2007). Guidelines for staging of pressure ulcers. [Brochure]. Hulse, J. (2011). Skin and Wound Care. Pesi Health Care. [Confrence]. Krasner, D., McNeil, M., & Weir, D. (2008). The Pressure’s On: Getting it Right on Admission. Norcross, GA: Molnlycke Health Care. Lippincott. (2011). Professional Guide to Pathophysiology (3rd ed.). Lippincott Williams and Wilkins. Ambler, PA. Maklebust, J., & Sieggreen, M. (2001). Pressure Ulcers: Guidelines for Prevention and Management. (3rd ed.). Ambler, PA. Lipponcott Williams and Wilkins. Molnlycke Health Care (2007). Mepilex Border Sacrum. [Brochure]. Norcross, GA. National Pressure Ulcer Advisory Panel. (2007). Pressure Ulcer Category/Staging Illustrations. Retrieved on April 1, 2011 from http://www.npuap.org/resources.htm. Nucleus Medical Media. (2011). Pressure Sores [youtube video] Retreived from http://www.youtube.com/watch?v=Eyuguc7KKC4&feature=player_ embedded#at=61.

References Cont. Oklahoma Foundation for Medical Quality. (2009 ). Appendix A: Glossary – Pressure Ulcer Terms. Retrieved on April 10, 2011 from http:// www.ofmq.com/Websites/ofmq/Images/SOS%20PU%20Toolkit/Appe ndix%20A.pdf . Porth, C., & Matfin, G. (2009). Pathophysiology Concepts of Altered Health States (p. 38-46). Philadelphia, PA: Lippincott Williams & Wilkins. Sage Products Inc. (2003). What the experts say about the financial implications of pressure ulcers. [Brochure]. Cary, Il. The Merck Manual of Geriatrics 3rd Edition (2000), (pp. 1317-1322). Whitehouse Station, NJ: Merck Research Laboratories. US Dept of Health & Human Services, National Institutes of Health (2010). Areas Where Bedsores Occur. [Online Image]. Retrieved on April 1, 2011 from http://www.nlm.nih.gov/medlineplus/ency/imagepages /19091.htm.