Transcript Preventing & Treating Pressure ulcers

Preventing &
Treating Pressure
Ulcers
By Kathleen Baldwin, RN, ANP, GNP, CNS, PhD
Nursing made Incredibly Easy! January/February 2006
3.0 ANCC/AACN contact hours
Online: www.nursingcenter.com
© 2006 by Lippincott Williams & Wilkins. All world rights reserved.
Pressure Ulcers 101
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Pressure ulcer: Any lesion caused by unrelieved
pressure that results in damage to the underlying tissue
(National Pressure Ulcer Advisory Panel)
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Small amount of pressure over long period is just as
damaging as large amount over short period.
Causes

Friction-Visible on skin surface; two surfaces move
against each other
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Shear-Injury beneath skin surface; patient’s skin moves
one way, bed sheets move opposite when moving
patient
Vulnerable Areas

Most common sites in adults: sacrum/coccyx and heels
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Most common sites in children not paralyzed: back of the
head (occiput)
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But the area over any bony prominence is vulnerable
Theories
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How do pressure ulcers develop?
• Theory one: Pressure ulcers begin at the bone and
move outward.
• Theory two: Pressure ulcers start from the skin and
work inward
Prevention is Key

Which patients are at risk?
• mobility deficit
• incontinence
• inadequate nutrition
• skin abnormalities
• increased age
• light skin pigment
• diabetes
• stroke
• hypotension
Identifying At-Risk Patients

Agency for Health Care Research & Quality
recommends two tools:
• Braden Scale-Most widely used; focuses on
intensity/duration of pressure & tissue tolerance for
pressure; www.bradenscale.com
• Norton Scale-Developed in United Kingdom; also
used, but not as often
JCAHO
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JCAHO 2006 national patient safety goal for long-term
care: prevention of health care-associated pressure
ulcers
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Predict, prevent, and provide early treatment:
• identify at-risk individuals
• protect patient from injury
• reduce pressure ulcers via education
Assessment Recommendations
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Acute care-On admission & every 24-48 hours, or when
patient condition changes
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Long-term care-On admission, then weekly for first 4
weeks, monthly to quarterly after that, & when patient
condition changes
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Home health care-On admission & every visit
Interventions
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Manage moisture
• Individualize bathing frequency
• Use a mild soap
• Don’t rub skin, pat dry
• Use moisture barrier on skin, incontinence products that pull
moisture away from skin
Interventions
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Manage nutrition
• Consult dietitian to correct diet deficits
• Ensure adequate intake of calories, protein, vitamin C, and zinc
Interventions

Manage mobility
• Elevate HOB no more than 30 degrees
• Use lift devices to prevent friction/shear
• Protect elbows, heels, sacrum
• Turn patients frequently
• PT consult to aid patient in mobility
• Specialty beds/mattresses for high risk patients
Pressure Ulcer Staging

Staging system developed by National Pressure Ulcer
Advisory Panel
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Stages I through IV; see www.npuap.org
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Can’t stage a pressure ulcer until the deepest viable
tissue layer is visible
Documenting Pressure Ulcers
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Location of pressure ulcer
Size (length & width)
Stage (indicates depth/damage)
Presence of sinus tracts
Amount/color/consistency/odor of exudate
Presence/absence of necrotic tissue
Presence/absence epithelialization
Types of Debridement

Sharp/surgical-Use of scalpel, scissors, forceps to remove dead
tissue; performed by physician and specially trained nurse or
therapist
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Mechanical-Use of force to remove dead tissue (wet-to-dry
dressings, irrigation)

Autolytic-Cover wound with dressing (films, occlusive, transparent)
and allow body’s natural wound fluids to loosen dead tissue
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Enzymatic-Enzyme applied to wound to remove dead tissue
(papain-urea, collagenase)
Last Words
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Dressings should be individualized!
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Pain should be assessed & adequately managed!
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Don’t massage bony prominences, use doughnut-type
devices, or allow skin to become dried out!