Chapter 31 Pressure Ulcers All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Pressure Ulcers (Decubitus Ulcers, Bed Sores, Pressure Sores) A pressure ulcer is a localized injury to the skin and/or underlying tissue. A pressure ulcer usually occurs over a bony prominence. Pressure, shearing, and friction are common causes. Pressure occurs when the skin over a bony area is squeezed between hard surfaces. Squeezing or pressure prevents blood flow to the skin and underlying tissues. See Figures 31-1 and 31-2, p. 523. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 2

Friction, Shear, and Pressure Ulcers Friction scrapes the skin, causing an open area. Shear is when the skin sticks to a surface while deeper tissues move downward. This occurs when the person slides down in the bed or chair. Unavoidable pressure ulcer Avoidable pressure ulcer The area opened by friction needs to heal. A good blood supply is needed. When friction scrapes the skin, a poor blood supply or an infection can lead to a pressure ulcer. Shear damages blood vessels and tissues. Blood flow to the area is reduced. According to the CMS, nursing centers must ensure that a person does not develop a pressure ulcer after entering the center. However, for some persons, a pressure ulcer occurs despite efforts to prevent one through proper use of the nursing process. This is called an unavoidable pressure ulcer. An avoidable pressure ulcer is one that develops from the improper use of the nursing process. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 3

CMS Standards CMS has standards about pressure ulcers. Nursing centers must evaluate each person’s condition and pressure ulcer risk factors. Identify and implement a comprehensive care plan and measures that meet the resident’s needs and goals. The care plan must include measures to reduce or remove a person’s risk factors. Centers must monitor and evaluate the effect of these measures and revise them as needed. Residents with a pressure ulcer must receive the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. Some persons are admitted to the center with pressure ulcers. Some persons’ risk may increase during an illness (cold, flu) or when their condition changes. Many pressure ulcers occur within the first 4 weeks of admission to a nursing center. A person at risk can develop a pressure ulcer within 2 to 6 hours after the onset of pressure. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 4

Risk Factors Risk factors include: Pressure Shearing Friction Immobility Breaks in the skin Poor circulation to an area Moisture Dry skin Irritation by urine and feces Older and disabled persons are at great risk for pressure ulcers. Their skin is easily injured. Causes include age-related skin changes, chronic disease, and general debility. Review Box 31-1 on p. 524. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 5

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 loss of bowel or bladder control Are exposed to moisture Have poor nutrition or poor fluid balance Have lowered mental awareness Have problems sensing pain or pressure Have circulatory problems Are older Are obese or very thin Refuse care Have a healed Stage 3 or 4 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. Moisture irritates the skin and increases the risk of damage from friction and shearing during re-positioning. A balanced diet is needed to properly nourish the skin. The risk for pressure ulcers increases when the skin is not healthy. Fluid balance is needed for healthy skin. Drugs and health problems affect mental awareness. If the person cannot sense pain or pressure, he or she does not know to alert the staff to the symptoms. Good blood flow is needed to bring oxygen and nutrients to the cells. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 6

CMS Requirements CMS requires that the person make informed choices. The center and resident must discuss the person’s condition, treatment options, expected outcomes, and problems from refusing treatment. The center must address the person’s concerns and offer options if a certain treatment is refused. The presence of a “Do Not Resuscitate” order (Chapter 44, p. 671) does not mean the person is refusing measures to prevent or treat a pressure ulcer. It only means that the person will not be resuscitated in the event of a cardiac or respiratory arrest. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 7

Stages Pressure ulcer stages Stage 1: The skin is red in persons with light skin. In persons with dark skin, skin color may differ from surrounding areas. Stage 2: Partial-thickness skin loss; it may involve a blister or shallow ulcer Stage 3: Full-thickness skin loss; subcutaneous fat may be exposed. Slough may be present. Stage 4: Full-thickness tissue loss with muscle, tendon and bone exposed and damaged. Slough and eschar may be present. Unstageable: Full-thickness tissue loss with the ulcer covered by slough and/or eschar. The color change that indicates Stage 1 of a pressure ulcer remains after the pressure is relieved. The area 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 31-2 on p. 525. See Figure 31-4A-E, p. 526. Review Focus on Communication: Pressure Ulcer Stages on p. 525. Slough is dead tissue that is shed from the skin. Usually light colored (yellow, tan, gray, green, or brown), soft, and moist, it may be stringy at times. Eschar is thick, leathery dead tissue that may be loose or adhered to the skin; it is tan, brown, or black. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 8

Sites Pressure ulcer sites Pressure ulcers usually occur over bony areas called pressure points. Common sites include the sacrum and heel. The ears also are sites for pressure ulcers. In obese people, pressure ulcers can occur in areas where skin has contact with skin. A pressure ulcer can develop where medical equipment is attached to the skin for a prolonged time. Pressure points bear the weight of the body in a certain position (Fig. 31-2, p. 523). Pressure from body weight can reduce the blood supply to the area. Pressure on the ear can result from the mattress when in the side-lying position. Eyeglasses and oxygen tubing also can cause pressure on the ears. Common skin-to-skin sites are between abdominal folds, the legs, the buttocks, the thighs, and under the breasts. 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. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 9

Ulcer Prevention and Treatment Good nursing care, cleanliness, and skin care are essential. The person at risk for pressure ulcers is placed on a support surface that reduces or relieves pressure. TJC and the CMS require pressure ulcer prevention programs. CMS requires use of the Minimum Data Set (MDS). Prevention involves identifying persons at risk and implementing prevention measures for them. Treatment The doctor orders wound care products, drugs, treatments, and special equipment to promote healing. The nurse assesses risk factors and skin condition when the resident is admitted to the center. Existing pressure ulcers are identified. Depending on the person’s condition and risk factors, he or she is assessed daily or weekly. The Braden Scale is a popular tool (Fig. 31-5, p. 527). The health team must develop a care plan for each person at risk. You must know and follow the care plan. Some centers use symbols or colored stickers on the person’s door or chart as pressure ulcer alerts to remind staff that the person is at risk for a pressure ulcer. Managing moisture, good nutrition and fluid balance, and relieving pressure are key measures. Review Box 31-3 on p. 528. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 10

Ulcer Prevention and Treatment (Cont’d) Protective devices are often used to prevent and treat pressure ulcers. Bed cradles Heel and elbow protectors Heel and foot elevators Gel- or fluid-filled pads and cushions Eggcrate-type pads Special beds Pillows, trochanter rolls, foot-boards, and other positioning devices Report and record any signs of skin breakdown or pressure ulcers at once. Review the descriptions of these protective devices on pp. 526-529. Review Teamwork and Time Management: Prevention and Treatment on p. 529. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 11

Dressings The nurse follows the orders of the treatment plan for the dressing to be applied. The wound must be moist enough to promote healing, but not too moist. For ulcers with drainage, an absorptive dressing is used. Wet-to-dry gauze is sometimes used. It absorbs slough, and is removed when the dressing is removed. If too moist, the dressing can interfere with healing. Review Chapter 30, p. 509 for more information on dressings. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 12

Complications TJC estimates that 60,000 people die each year from pressure ulcer complications. Infection is the most common complication. According to the CMS, all Stage 2, 3, and 4 pressure ulcers are colonized with bacteria. Other complications Osteomyelitis Pain Amputation Longer nursing center stays Colonized refers to the presence of bacteria on the wound surface or in wound tissue. The person does not have signs and symptoms of an infection. Wounds are infected if the person has signs and symptoms of infection (Chapter 13, p. 176). For some persons pain and delayed healing signal an infection. For the pressure ulcer to heal, infection must be diagnosed and treated. Osteomyelitis is a risk if the pressure ulcer is over a bony prominence, especially if the ulcer is not healing. The person has severe pain and is treated with bedrest and antibiotics. Careful and gentle positioning is needed. Surgery may be necessary to remove dead bone and tissue. Pain management is important (Chapter 24, p. 408). Pain may interfere with movement and activity. The immobility is a risk factor for pressure ulcers, and it may delay healing of an existing pressure ulcer. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 13

Reporting and Recording Report and record any signs of skin breakdown at once. Report and record any signs of pressure ulcers at once. See “Wound Appearance” (Chapter 30, p. 507). Review Focus on Communication: Reporting and Recording on p. 531. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 14

Quality of Life The Omnibus Budget Reconciliation Act of 1987 (OBRA), the CMS, and TJC require a care plan for each person. It must address correct skin care. Residents have the right to care that promotes healthy skin and prevents skin breakdown and pressure ulcers. Everyone must keep the person’s skin healthy. Follow the person’s care plan. Be very careful not to injure the skin during care. Treat the person with dignity and respect. Use skin care products and protective devices as directed by the nurse and the care plan. The skin is the body’s first line of defense against changes in the environment. Keep the skin clean and intact to promote comfort and prevent infection. Giving good skin care is an important part of your job. Pressure ulcers reduce a person’s quality of life. Depression and death are risks. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 15