1. Pressure Ulcers in the Critically Ill Patient
Jamie Oelschlaeger, RN-BSN
MRICU, St. Luke’s Medical Center
Alverno College
MSN Program
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Review questions will be located through out the tutorial. To re-visit the material presented in the question, click the hyperlink located in the answer box located on the slide

3. Main Menu Stage I Stage II Stage III Stage IV Deep Tissue Injury
Integumentary Review
Pathophysiology of Integumentary System
Introduction to Pressure Ulcers
Stage I
Stage II
Stage III
Stage IV
Deep Tissue Injury
Unstageable Ulcers
Role of Inflammation
Role of Genetics
Role of Stress Response
Commonly Affected Areas
Risk Factors
Nursing Interventions
Case Study

4. Learning Objectives By the end of this presentation, the learner will:
Identify and differentiate the different stages of pressure ulcers
Understand the difference between pressure ulcers, deep tissue injury, and unstageable ulcers
Identify risk factors associated with the development of pressure ulcers

5. Review of the Integumentary System
Largest organ of human body
Protective function
Regulates temperature with in the body
Storage for water and fat
Prevents loss of water
Prevents bacterial invasion
The Ohio State University Medical Center (n.d.)
Image provided by Microsoft clipart

6. Review of the Integumentary System
Skin is composed of 3 layers:
Epidermis
Outer most layer
Prevents bacteria from penetrating
Prevents loss of water
Dermis
Middle layer
Contains blood vessels, sweat glands, and nerves
Subcutis
Inner most layer
Contains collagen and fat
Regulates body temperature
The Ohio State University Medical Center (n.d.)
Picture used for education purposes from the National Pressure Ulcer Advisory Panel (200&

7. Pathophysiology of the Integumentary System
The epidermis thins
Changes in connective tissue result in less elasticity and strength
Blood vessels in dermis become fragile
The subcutaneous layer thins
Reduced sensation of touch, pressure, temperature
U.S. National Library of Medicine (2011)
MedicineNet (2011)
Web MD (2011)
Picture provided by Microsoft clipart

8. Pathophysiology of the Integumentary System
Skin becomes vulnerable to injury
Thinning skin and loss of subcutaneous tissue decrease protection
Increased possibility of blood vessel rupture
U.S. National Library of Medicine (2011)
MedicineNet (2011)
Web MD (2011)
Picture provided by Microsoft clipart

9. Test Your Knowledge!
The subcutaneous layer of the skin thins with aging.
True
False
Right on!
No! A normal part of aging in skin includes thinning of the subcutaneous layer of skin.

10. Introduction to Pressure Ulcers
A pressure ulcer is an area of tissue damage that occurs when the skin and tissues are compressed between bones and a surface which has direct contact with the body
Occurs most frequently over a bony prominence
Classified into four stages based on appearance
The AGS Foundation for Health and Aging (2011)
National Pressure Ulcer Advisory Panel (2007)

11. Stage I Pressure Ulcer Skin is intact
NON-BLANCHABLE redness present over in localized area over bony prominence
Affected area may be:
Painful
Firm
Warmer
National Pressure Ulcer Advisory Panel (2007)
Picture used for education purposes from the National Pressure Ulcer Advisory Panel (2007)

12. Stage II Pressure Ulcer
Loss of partial thickness to dermis
Shallow or open area
Pink and red wound bed
Slough is not present
Affected area will be:
Shiny or dry
No slough or bruising
National Pressure Ulcer Advisory Panel (2007)
Picture used for educational purposes from the National Pressure Ulcer Advisory Panel (2007)

13. Stage This Ulcer!
Try again! This ulcer is not intact! I
Click the link below to view the pressure ulcer from Arnold (2007)!
Good Job! II
Try Again! This ulcer does not penetrate beyond the dermis! IV
No! This ulcer is not purple/maroon in appearance!
Deep Tissue Injury

14. Stage III Pressure Ulcer
Loss of partial thickness to dermis
Shallow or open area
Pink and red wound bed
Slough is not present
Affected area will be:
Shiny or dry
No slough or bruising
National Pressure Ulcer Advisory Panel (2007)
Picture used for educational purposes from the National Pressure Ulcer Advisory Panel (2007)

15. Stage IV Pressure Ulcer
Full thickness tissue loss
Exposed bone, tendons, and/or muscle
Slough or eschar may be present
Affected area may include:
Undermining
Tunneling
National Pressure Ulcer Advisory Panel (2007)
Picture used for educational purposes from the National Pressure Ulcer Advisory Panel (2007)

16. Stage This Ulcer!
Try again! This ulcer has more than just a open pink wound bed! II
Click the link below to view the pressure ulcer from the University of Washington (2011)!
Perfect
III
Nice try! This ulcer does not expose tendon or bone! IV
Not this one! This ulcer does not have a necrotic wound bed
Unstageable

17. Deep Tissue Injury Skin intact or blood-filled blister
Localized area purple or maroon in color
Underlying soft tissue affected
Affected area may be:
Painful
Firm
Boggy
Warmer
National Pressure Ulcer Advisory Panel (2007)
Used for educational purposes from the National Pressure Ulcer Advisory Panel (2007)

18. Unstageable Ulcers Full thickness tissue loss
Base of ulcer covered by slough and/or eschar
Once slough and/or eschar is removed, the ulcer can be staged
National Pressure Ulcer Advisory Panel (2007)
Used for educational purposes from the National Pressure Ulcer Advisory Panel (2007)

19. Stage This Ulcer!
Try again! This ulcer does not have an open wound bed! II
Click the link below to view the pressure ulcer from Medscape (2011)!
Not this one! This ulcer does not penetrate beyond the dermis!
III
Try again! This ulcer is not purplish in appearance!
Deep Tissue Injury
Correct!
Unstageable

20. Role of Inflammation
Increased pressure, moisture, friction and shear damage underlying tissues of skin
Damaged tissue releases prostaglandins and leukotrienes
WBC collect to the site of injury
Vasodilation occurs at the site
Increased venule permeabilty occurs with in the venules
Porth (2005)
Picture provided by Microsoft clipart

21. Role of Inflammation
Exudate leaks out of the venules and into the surrounding tissue
Decreased blood volume to site of injury
Tissues swell causing edema
Pressure on nerves cause pain
Pressure ulcers develop as a result
Inflammation is the first sign of pressure ulcer development!
Porth (2005)
Picture provided by Microsoft clipart

22. Test Your Knowledge!
Inflammation does not play a role the development of pressure ulcers.
True
False
Try Again! The inflammatory response play a large role in pressure ulcer development
That is correct!

23. Role of Genetics
There is no genetic predisposition in developing pressure ulcers
Genetic disorders and diseases can increase risk of pressure ulcer development though:
Interference with healing
Increased fragility with in blood vessels and skin
Lack of sensation in limbs
Porth (2005)
Picture provided by Microsoft clipart

24. Role of Genetics
Diabetes is a genetic disease that can cause neuropathy over time and result in loss of sensation in limbs
Loss of sensation can lead to an inability to feel temperature and pressure increasing the risk of pressure ulcers to develop
Peripheral vascular disease is a genetic disorder that causes blood vessel constriction or occlusion decreasing blood flow to affected area
Loss of blood flow causes a decrease in oxygen and nutrients which leads to cell death and increase pressure ulcer risk
American Diabetes Association (2010)
Columbia University Medical Center Department of Surgery (2011)
Picture provided by Microsoft clipart

25. Role of Genetics
Cerebral Palsy and muscular dystrophy are examples of genetic disorders that cause physical disabilities which can result in paralysis of limbs
Paralysis leads to the inability to move limbs voluntarily
Lack of movement increases risk of pressure, friction, and shear on skin
Pressure ulcers can develop as a result
National Institute of Neurological Disorders and Stroke (2010)
Porth (2005)
Picture provided by Microsoft clipart

26. Test your knowledge!
Diabetes can cause neuropathy which results in loss of sensation, inability to sense temperature, and pressure.
True
False
That is correct!
Try again! Neuropathy does result in loss of sensation, pressure, and temperature!

27. Role of the Stress Response
Under stress, the sympathetic nervous system responds
Epinephrine and norepinepherine are released into the blood stream and attach to receptor molecules on the surface of cells
Alpha 1 receptors cause decreased blood flow to skin
Sweating often occurs
Beta 1 receptors increase the metabolic rate
Fat stores release fat into blood stream
Porth (2005)
Picture provided by Microsoft clipart

28. Role of the Stress Response
Decreased blood flow to skin results in lack of nutrients and oxygen
Sweating increases moisture and risk of friction and shear
Release of fat into the blood stream may decrease protective layer for underlying tissues
Porth (2005)
Picture provided by Microsoft clipart

29. Test your Knowledge!
Sweating increases moisture and the risk of friction and shear.
True
False
Right on!
No! Sweating does cause additional moisture which increases friction and shear

30. Commonly Affected Areas
Pressure on bony prominences restrict blood flow to vulnerable areas
Restricted blood flow decreases oxygen and nutrients
Cell death can occur at area if pressure is not relieved
Mayo Foundation for Medical Education and Research (2011)
Porth (2005)
Elbows
Hips
Ankles
Shoulder blades
Back or side of the head
Rim of ears
Heels
Toes
Bridge of nose
Sacrum
Coccyx

31. Risk Factors Bedridden or wheelchair bound Aging Fragile skin
Increased risk of pressure on bony prominences and decreased blood flow to vulnerable areas
Aging
The epidermis thins and blood vessels become more fragile
Fragile skin
Increased risk of shearing and tearing of skin
Urinary or bowel incontinence
Causes skin breakdown and increased moisture
Malnourishment
Lack of vitamins and nutrients prevent healing
Smoking
Nicotine reduces oxygen level in blood and impairs circulation
Mayo Foundation for Medical Education and Research (2011)
Porth (2005)
Picture provided by Microsoft clipart

32. Risk Factors Decreased mental awareness Weight loss Paralysis
Mental inability to shift weight to relieve pressure appropriately
Weight loss
Lower fat stores decreases protective layer for underlying tissue
Paralysis
Lack of limb movement increases risk of pressure on vulnerable areas
Vascular disease
Increased fragility of blood vessel rupture and decreased blood flow with in vessels
Diabetes
Loss of sensation from neuropathy and poor wound healing
Mayo Foundation for Medical Education and Research (2011)
Porth (2005)
Picture provided by Microsoft clipart

33. Test your knowledge!
High activity levels can result in the development of pressure ulcers.
True
False
No! Higher levels of activity are encouraged! Increased blood flow to different parts of the body increases tissue oxygenation and delivery of nutrients.
Correct!

34. Nursing Interventions
Turn bed bound patients every 2 hours
Encourage patients to shift weight in chair every 15 minutes
Repositioning relieves pressure on vulnerable bony prominences
Mayo Foundation for Medical Education and Research (2011)
U.S. National Library of Medicine (2010)
Picture provided by Microsoft clipart

35. Nursing Interventions
Use pressure alleviating mattresses and pads
Use pillows or foam wedges to prevent contact with bony prominences
Mayo Foundation for Medical Education and Research (2011)
U.S. National Library of Medicine (2010)
Picture provided by Microsoft clipart

36. Nursing Interventions
Apply moisture barriers and protective films to prevent moisture and skin breakdown
Apply protective, pressure alleviating dressings to open wounds
Mayo Foundation for Medical Education and Research (2011)
U.S. National Library of Medicine (2010)
Picture provided by Microsoft clipart

37. Nursing Interventions
Encourage fluid intake to maintain skin integrity
Encourage a diet rich in protein, vitamins, and minerals to promote healing
Encourage daily exercise to increase blood flow to skin
Mayo Foundation for Medical Education and Research (2011)
U.S. National Library of Medicine (2010)
Picture provided by Microsoft clipart

38. Test Your Knowledge!
Pressure alleviating mattresses are not helpful in pressure ulcer prevention.
True
False
No! Pressure alleviating mattresses play a key part in pressure ulcer prevention!
That is correct!

39. Case Study
Mr. H, a 75 year old male, is admitted to the ICU from the OR status post cholecystectomy. His past medical history includes: diabetes, peripheral vascular disease, and currently smokes 2 packs per day.
Picture provided by Microsoft clipart

40. Case Study
Mr. H experienced a number of complications during the case which extended his surgery to 8 hours. Because of his critical status, the physician ordered Mr. H to remain intubated overnight, NPO, and strict bed rest for the first 24 hours post-op.
Picture provided by Microsoft clipart

41. Case Study
You are the nurse taking care of Mr. H 24 hours after his surgery. He remains on the ventilator and NPO but is off bed rest. You walk into the room to perform your assessment.
Picture provided by Microsoft clipart

42. Case Study
As you are turning Mr. H onto his side, you notice an area on his coccyx that looks like this: Click the link below to view the pressure ulcer from Medscape (2011)!

43. Case Study How would you describe the ulcer you assessed on Mr. H?
Skin Intact
Localized
Non-blanchable erythema
Skin Intact
Localized
Purple/Maroon appearance
Skin opened
Localized
Wound bed pink
Not this one! The ulcer does not have non-blanchable erythema
Perfect!
Try again! The ulcer is not open with a pick wound bed

44. Not this one! This is not a stage I
Case Study
Based on your assessment findings, how would you stage the ulcer? I II
Deep Tissue Injury
Correct!
Not this one! This is not a stage I
Try Again!
It is not a stage II

45. Case Study
What risk factors make Mr. H more prone to developing pressure ulcers?
Smoking history
Good Job!
Diabetes
Yes!
Pancreatitis
Not this one!
CPOD
Not a risk factor!
PVD
Correct!
Bed ridden
Right On!

46. Case Study
What nursing interventions could have been executed to prevent Mr. H from developing an injury?
Turning every 2 hours
Lying supine continuously
Using a pressure alleviating mattress
Applying moisture barrier cream
Sorry! Lying in one position continuously is a common cause of pressure ulcers!
Correct!
Perfect!
You got it!

47. Reference
AGS Foundation for Health in Aging, The. Pressure ulcers (bed sores). Retrieved February 2, 2011 from American Diabetes Association. (2010). Genetics of diabetes. Retrieved April 5, 2011 from Columbia University Medical Center Department of Surgery. Peripheral vascular disease: Cutting edge therapies and studies at New-York Presbyterian hospital. Retrieved March 31, 2011 from Long, M.A. (2007). New and improved: 2007 pressure ulcer definitions. Retrieved April 13, 2011 from SNJourney Web Site: Mayo Foundation for Medical Education and Research. (2011) Bed sores (pressure sores). Retrieved February 10, 2011 from MedicineNet. (2011). The effects of aging on your skin. Retrieved March 20th 2011 from Medscape. (2011). The Unavoidable Pressure Ulcer: Taking a Stand: Avoidable and Unavoidable Pressure Ulcers. Retrieved April 13, 2011 from Medscape. (2011). Pressure Ulcers, Nonsurgical Treatment and Principles. Retrieved April 13th, 2011 from

48. Reference
National Institute of Neurological Disorders and Stroke. (2010). NINDS cerebral palsy information page. Retrieved March 15, 2011 from
National Institute of Neurological Disorders and Stroke. (2010). NINDS muscular dystrophy information page. Retreived from
National Pressure Ulcer Advisory Panel. (2007). Pressure ulcer stages revised by NPUAP. Retrieved February 28, 2011 from
Ohio State University Medical Center. (n.d.) Anatomy of the skin. Retrieved March 23, 2011 from
Porth, C.M. (2005). Pathophysiology.
University of Washington. (2011). Skin care and pressure sores. Retrieved April 13, 2011 from
U.S. National Library of Medicine. (2010). Diabetic neuropathy. Retrieved March 5, 2011 from
U.S. National Library of Medicine. (2010). Pressure ulcer. Retrieved February 15, from
Web M.D. (2011). The effects of aging on skin. Retrieved March 22, 2011 from

49. The End!
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