Chapter 34 Pressure Ulcers Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Pressure Ulcers Before defining pressure ulcers, “You need to understand these terms” Bony prominence—area where the bone sticks out or projects from the flat surface of the body Shear—when layers of the skin rub against each other, or when the skin remains in place and underlying tissues move and stretch and tear underlying capillaries and blood vessels Friction—the rubbing of one surface against another The back of the head, shoulder blades, elbows, hips, spine, sacrum, knee, ankles, heels, and toes are bony prominences. These area are sometimes called pressure points. Shearing causes tissue damage. With friction, the skin is dragged across a surface. Friction is always present with shearing. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Pressure Ulcers (cont’d) Pressure ulcers are defined by: The National Pressure Ulcer Advisory Panel (NPUAP)—a localized injury to the skin and/or underlying tissue usually over a bony prominence The Centers for Medicare & Medicaid Services (CMS)—any lesion caused by unrelieved pressure that results in damage to underlying tissues According to the NPUAP, pressure ulcers are the result of pressure in combination with shear and/or friction. Decubitus ulcer, bed sore, or pressure sore are other terms for pressure ulcers. According to the CMS, friction and shear are not the main causes of pressure ulcers. However, friction and shear are important contributing factors. Review the Focus on Long-Term Care and Home Care: Pressure Ulcers Box on p. 595 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Risk Factors Pressure is the major cause of pressure ulcers. Risk factors include breaks in the skin, poor circulation to an area, moisture, dry skin, irritation by urine and feces. Skin and tissues die. Friction scrapes the skin, causing an open area. A poor blood supply or an infection can lead to a pressure ulcer. Shear occurs when the person slides down in the bed or chair. Blood vessels and tissues are damaged. Blood flow to the area is reduced. See Box 34-1 on p. 595 in the Textbook for common causes of skin breakdown. Shearing and friction are important factors. Pressure occurs when the skin over a bony area is squeezed between hard surfaces. The bone is one hard surface. The other is usually the mattress or chair seat. Squeezing or pressure prevents blood flow to the skin and underlying tissues. Oxygen and nutrients cannot get to the cells. The open area needs to heal. A good blood supply is needed. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Persons at Risk Persons at risk for pressure ulcers are those who: Are bedfast or chairfast Need some or total help in moving Are agitated or have involuntary muscle movements Have urinary or fecal incontinence Are exposed to moisture Have poor nutrition Have poor fluid balance Have lowered mental awareness Have problems sensing pain or pressure Have circulatory problems Are obese or very thin Have a healed pressure ulcer Pressure occurs from lying or sitting in the same position for too long. Coma, paralysis, or a hip fracture increases the risk for pressure ulcers. The person’s movements cause rubbing (friction) against linens and other surfaces. Urine, feces, wound drainage, sweat, and saliva expose the person to moisture, which irritates the skin. Pressure ulcer risk increases when the skin is not healthy. Cells and tissue die when starved of oxygen and nutrients. Review the Focus on Children and Older Persons: Persons at Risk Box on p. 596 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Pressure Ulcer Stages Skin color change remaining after pressure is relieved. Persons with light skin—a reddened bony area Persons with dark skin—skin color differs from surrounding areas The skin may feel warm or cool. The person may complain of pain, burning, tingling, or itching in the area. Some persons do not feel anything unusual. Review Box 34-2 on p. 597 in the Textbook for the description of pressure ulcer stages. Review the Focus on Communication: Pressure Ulcer Stages Box on p. 596 in the Textbook. Review the Focus on Long-Term Care and Home Care: Pressure Ulcer Stages Box on p. 596 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Sites Pressure ulcers usually occur over bony prominences (pressure points). These areas bear the weight of the body in a certain position. According to the CMS, the sacrum is the most common site for a pressure ulcer. Other sites include: Heels Ears Areas where medical equipment is attached to skin Areas where skin has contact with skin Pressure from body weight can reduce the blood supply to the area. Pressure on the ear from the mattress when in the side-lying position may cause a pressure ulcer. Eyeglasses and oxygen tubing also can cause pressure on the ears. A urinary catheter can cause pressure and friction on the meatus. Tubes, casts, braces, and other devices can cause pressure on arms, hands, legs, and feet. In obese people, pressure can occur from friction between abdominal folds, legs, buttocks, thighs, and under the breasts. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Prevention and Treatment Good nursing care, cleanliness, and skin care are essential. The Joint Commission (TJC) and the CMS require pressure ulcer prevention programs. Prevention includes: Identifying persons at risk Some agencies use symbols or colored stickers as pressure ulcer alerts. Implementing prevention measures for those at risk Support surfaces are used to relieve or reduce pressure. Following the person’s care plan Preventing pressure ulcers is much easier and more cost effective than trying to heal them. Pressure ulcers occur in hospitals, long-term care, and home settings. The nurse assesses the person when he or she is admitted to the agency. The Braden Scale for Predicting Pressure Sore Risk is a popular tool. Existing pressure ulcers are identified. Depending on the person’s condition and risk factors, he or she is assessed daily or weekly. Managing moisture, good nutrition and fluid balance, and relieving pressure are key measures. The measures in Box 34-3 on p. 598 in the Textbook may be part of the person’s care plan to prevent skin breakdown and pressure ulcers. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Prevention and Treatment (cont’d) The doctor orders wound care products, drugs, treatments, and special equipment to promote healing. The nurse and care plan tell you what to do. Protective devises commonly used include bed cradle, heel and elbow protectors, heel and foot elevators, gel or fluid-filled pads and cushions, eggcrate-type pads, special beds, and other equipment. The nurse decides what dressing to use. Wet dressings are used sometimes. A dressing that absorbs drainage is used if the pressure ulcer has drainage. The dressing absorbs slough. The slough is removed when the dressing is removed. A bed cradle prevents top linens from applying pressure on the legs, feet, and toes. Heel and elbow protectors are made of materials that promote comfort and reduce shearing and friction. Heel and foot elevators prevent pressure by raising the heel and foot off the bed. Some also prevent footdrop. Gel or fluid-filled pads and cushions prevent pressure while the person is in a chair or wheelchair. Eggcrate-type pads are placed on beds or in chairs or wheelchairs to distribute the person’s weight more evenly and protect against heat, moisture, and soiling. Special beds are useful for persons with spinal cord injuries. Pillows, trochanter rolls, foot-boards, and other devices are used to help keep the person in good alignment. Review the Teamwork and Time Management: Prevention and Treatment Box on p. 598 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Complications Infection is the most common complication. Colonized—the presence of bacteria on the wound surface or in wound tissue. The person does not have signs and symptoms of an infection. Osteomyelitis—inflammation of the bone and bone marrow. This is a risk if the pressure ulcer is over a bony prominence. The person has severe pain. Pain management is important. Pain may affect movement and activity. Immobility is a risk factor for pressure ulcers. It may delay healing of an existing pressure ulcer. According to the CMS, all Stages 2, 3, and 4 pressure ulcers are colonized with bacteria. For some persons, pain and delayed healing signal an infection. Infection must be diagnosed and treated for the pressure ulcer to heal. With osteomyelitis, the person is treated with bedrest and antibiotics. Surgery may be needed to remove dead bone and tissue. Careful and gentle positioning is needed. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Reporting and Recording Report and record any signs of skin breakdown or pressure ulcers at once. Review the Focus on Communication: Reporting and Recording Box on p. 603 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.