Pressure Ulcers in the Critically Ill Patient

1. Jamie Oelschlaeger, RN-BSN MRICU, St. Luke’s Medical Center Alverno College MSN Program Pressure Ulcers in the Critically Ill Patient Click here to get started!

2. To Navigate this Tutorial… • To advance to the next slide, click • To return back to the main menu at any time, click • To view the previous slide, click • To view the last seen slide, click • 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 Integumentary Review Pathophysiology of Integumentary System Introduction to Pressure Ulcers Stage I Stage III Stage IV Deep Tissue Injury Stage II Role of Stress Response Unstageable Ulcers Role of Inflammation Role of Genetics 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! Click the link below to view the pressure ulcer from Arnold (2007)! http://www.snjourney.com/Images/pustage2.gif Try again! This ulcer is not intact! I 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)! http://msktc.washington.edu/images/stage_3_Merck.jpg 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! Click the link below to view the pressure ulcer from Medscape (2011)! http://img.medscape.com/pi/emed/ckb/rehabilitation/305143-317514-319284-1714350.jpg II 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 venulepermeabilty 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 That is correct! Try Again! The inflammatory response play a large role in pressure ulcer development

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 • 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 • 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 That is correct! No! Pressure alleviating mattresses play a key part in pressure ulcer prevention!

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)! http://img.medscape.com/article/715/969/715969-fig1.jpg

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. 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! Pancreatitis Not this one! Diabetes Yes! 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 http://www.healthinaging.org/agingintheknow/chapters_ch_trial.asp?ch=30 American Diabetes Association. (2010). Genetics of diabetes. Retrieved April 5, 2011 from http://www.diabetes.org/diabetes-basics/genetics-of-diabetes.html 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 http://www.columbiasurgery.org/news/healthpoints/2009_fall/p3.html Long, M.A. (2007). New and improved: 2007 pressure ulcer definitions. Retrieved April 13, 2011 from SNJourney Web Site: http://www.snjourney.com/ClinicalInfo/Systems/Intrgum/newstagepu.htmMayo Foundation for Medical Education and Research. (2011) Bed sores (pressure sores). Retrieved February 10,2011 from http://www.mayoclinic.com/print/bedsores/DS00570/DSECTION=all&METHOD=print MedicineNet. (2011). The effects of aging on your skin. Retrieved March 20th 2011 from http://www.medicinenet.com/script/main/art.asp?articlekey=43078 Medscape. (2011). The Unavoidable Pressure Ulcer: Taking a Stand: Avoidable and Unavoidable Pressure Ulcers. Retrieved April 13, 2011 from http://img.medscape.com/article/715/969/715969-fig1.jpg Medscape. (2011).Pressure Ulcers, Nonsurgical Treatment and Principles. Retrieved April 13th, 2011 from http://img.medscape.com/pi/emed/ckb/rehabilitation/305143-317514-319284-1714350.jpg

48. Reference National Institute of Neurological Disorders and Stroke. (2010). NINDS cerebral palsy information page. Retrieved March 15, 2011 from http://www.ninds.nih.gov/disorders/cerebral_palsy/cerebral_palsy.htm National Institute of Neurological Disorders and Stroke. (2010). NINDS muscular dystrophy information page. Retreived from http://www.ninds.nih.gov/disorders/md/md.htm National Pressure Ulcer Advisory Panel. (2007). Pressure ulcer stages revised by NPUAP. Retrieved February 28, 2011 from http://www.npuap.org/pr2.htm Ohio State University Medical Center. (n.d.) Anatomy of the skin. Retrieved March 23, 2011 from http://medicalcenter.osu.edu/patientcare/healthcare_services/skin_conditions/anatomy_skin/Pages/index.aspx Porth, C.M. (2005). Pathophysiology. University of Washington. (2011). Skin care and pressure sores. Retrieved April 13,2011 from http://msktc.washington.edu/images/stage_3_Merck.jpg U.S. National Library of Medicine. (2010). Diabetic neuropathy. Retrieved March 5, 2011 from http://www.nlm.nih.gov/medlineplus/ency/article/000693.htm U.S. National Library of Medicine. (2010). Pressure ulcer. Retrieved February 15, 2011 from http://www.nlm.nih.gov/medlineplus/ency/article/007071.htm Web M.D. (2011). The effects of aging on skin. Retrieved March 22, 2011 from http://www.webmd.com/skin-beauty/guide/cosmetic-procedures-agingskin

49. The End! Thank you for participating in this tutorial! Your feedback is appreciated! Please take a few minutes to complete a brief evaluation of this learning experience!