Transcript Background # 4 - Alverno College

Dipti Jethani RN BSN
Alverno College
All motion clips/images not labeled obtained from Microsoft Clip Art
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Objectives
Incidence
Risk Factors
Stages of Ulcers
Prevention
Pathophysiology
Complications
Treatment
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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
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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/.
a.
b.
c.
d.
e.
Age
Lack of Mobility
Diabetes
Having Pneumonia
Having a cane – she’ll beat the nurses up!
Click Here To Read
Case Study Narrative
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Three Layers
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Epidermis
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Dermis
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Outermost Layer
Contains sensory receptors for
pain, temp, touch, vibration, and
pressure detection
Barrier to preserve moisture,
vitamins, minerals, and proteins
Lies beneath the epidermis,
deeper and thicker too
Contains connective tissue, &
sebaceous glands
Contains fat &sweat glands
Subcutaneous Tissue
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Layer of fat and connective tissue
Layer of insulation to conserve
body heat
Lippincott Williams and Wilkins, 2011
National Pressure Ulcer Advisory Panel (2007).
For Educational Purposes.
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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/1909
1.htm
For Educational Purposes, NIH
Lippincott Williams and Wilkins, 2011
Estimated: 1 mill/yr;
annual cost = $1.6
billion
The elderly account for
> 60% of decubitus
patients
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
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)
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
Most often seen in
elderly
Bedridden; Chair
Bound
Mereck Manual of Geriatrics, 2000; Krasner (2008).
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Extrinsic Factors
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Pressure
Friction
Shearing
Intrinsic Factors
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Immobility
Inactivity
Incontinence
Malnutrition
Age
Mental Status
Mereck Manual of Geriatrics, 2000
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BEGINS ON
ADMISSION
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Skin Exam
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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
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Braden Scale
Norton Scale
PUSH Tool
Guren, D., 2010.
•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.
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BEGINS AT FIRST CONTACT
Turn patient at least every 2 hours
Do not place pts in a 90 degree lateral position
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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
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Patient should not sit
more than 2 hours
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Sitting position puts
increased pressure on
ischial tuberosities.
Reposition patient every
hour in chair
Teach patient to shift
weight every 15 minutes
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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:
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Mereck Manual of Geriatrics, 2000
Keep pressure off the
area of breakdown
Clean and dress the
wound
Maintain good nutrition
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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)
Gel Flotation
Pads
Alternating
Pressure
Mattress
Sheep Skin
Convoluted
Foam
Mattress
Heel Boots
Spanco
Mattress
Low Air Loss
Bed
Air-Fluidized
Bed
Lippincott Williams and Wilkins, 2011
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Most Develop Over 5
locations:
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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
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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.
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
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6 Stages
Staged according to
depth of damage
Bright Hub Inc, 2011. Public Domain Image
Mereck Manual of Geriatrics, 2000
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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:
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Painful
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Mushy, firm, or boggy
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Warmer or cooler as
compared to other tissue
National Pressure Ulcer Advisory Panel (2007).
For Educational Purposes.
Abrass, 2004
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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.
Abrass, 2004
National Pressure Ulcer Advisory Panel (2007).
For Educational Purposes.
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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:
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Perineal dermatitis,
maceration, tape burns, skin
tears or excoriation .
Only use to describe
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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
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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
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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
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Involves full-thickness tissue
loss.
The base of the ulcer is covered
by :
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Slough: yellow, tan, gray,
green, or brown OR
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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
Abrass, 2004
National Pressure Ulcer Advisory Panel (2007).
For Educational Purposes.
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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
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Which of the following is Grace most at risk
for?
a.
b.
c.
d.
Friction
Shearing
Maceration
Laceration
Click Here To Read
Case Study Narrative
Click Here To Read
Case Study Narrative
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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.
Affected area becomes hypoxic and ischemic d/t
press exerted on it

Decreased blood flow to site
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Capillaries Collapse, Thrombosis occurs
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Tissue Edema/Necrosis
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Accumulation of waste products at site
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Tissue Breakdown
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Cell Death
Lippincott Williams and Wilkins, 2011
Stress occurs
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Adrenal Glands produce Epi
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SNS releases NE
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NE causes peripheral vasoconstriction
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Decreased Oxygen Delivery
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Epi enhances production of chalone
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Chalone protein depresses regeneration of
epidermal tissue
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Tissue Breakdown
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Cell Death
Epi = Epinephrine NE = Norepinephrine
Place mouse over chalone to see
definition
Maklebust, J., & Sieggreen, M. (2001).
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Muscle & fat are lost with
aging (to spread out press)
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Skin Elasticity Decreases
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 in ascorbic acid levels:
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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:
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Repair rate declines
Cell proliferation es
Wound tensile strength es
Collagen deposition es
Lippincott Williams and Wilkins, 2011; Mereck Manual of Geriatrics, 2000
Damaged BVs
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Exposed Collagen
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With Thrombin exposed collagen stimulates platelet activity
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Activation, aggregation, and adhesion of platelets and
release mediators
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Stimulates Vasoactive substances
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Breakdown products attract nuetrophils and macrophages
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Monocytes become Macrophages

Release growth factors
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Trigger Fibroblasts to secrete collagen & proteins
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Wound becomes beefy red and bleeds
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Vasculature begins to restore
Hulse, 2011
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Study by Bregstorm & Braden
(2002)
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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
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Capezuti, 2008
Mereck Manual of Geriatrics, 2000
Predisposed to developing
pressure sores
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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.
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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
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Prevention Strategies
Pressure Reduction
Avoiding Friction/ Shearing
Forces
Stage III/IV
 Debridement of
necrotic tissue
 Freq Irrigation (2-3x/d)
 Dressing of the wound
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Encourage movement
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Abrass, 2004; Anders, 2010
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!!
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Need adequate intake for
wound healing and immune
response
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Incr protein/caloric intake
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Supplement with multivitamins (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
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
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Location
Size
Dressing
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Type of irrigation soln, drsg
applied
Drainage
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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
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a.
b.
c.
d.
e.
f.
What aspect of Grace’s existing condition is the
most influencing factor for increasing her risk
for pressure ulcers?
Pneumonia/COPD
Diabetes
Click Here To Read
Case Study Narrative
Venous Insufficiency
Lack of Mobility
None of the Above
All of the Above
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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?v=Eyuguc7KKC4&feature=play
er_embedded#at=61 (Click here to see video)
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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
Questions? Email [email protected]
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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.
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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.
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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.