PREVENTION AND TREATMENT OF PRESSURE ULCERS

1. PREVENTION AND TREATMENT OF PRESSURE ULCERS By Holly Ferguson, PT, WCC

2. PURPOSE The purpose of this self-learning module is to help guide nurses performing skin assessment and care according to best practice. At the end of the module, the nurse will be able to: • Identify skin assessment protocol • Identify risk factors for developing pressure ulcers • Identify at least 3 things to help prevent pressure ulcers • Identify the SJH nursing and interdisciplinary team resources • Identify ways to manage and treat pressure ulcers

3. What is skin?

4. Skin Structure and Function

5. NPUAP DEFINITION (National Pressure Ulcer Advisory Panel) a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

6. PRESSURE ON VESSELS Unrelieved pressure on the skin squeezes tiny blood vessels, which supply the skin with nutrients and oxygen. When the skin is starved for too long, the tissue dies, and a pressure ulcer develops

7. BONY PROMINENCES

8. COMMON SITES

9. CLINICAL PRESENTATION • Rounded, crater like shapes with regular edges • Over bony prominences, but can take on the shape of the bone (malleoli vs sacrum) • Usually dark regular base that do not bleed easily • 95% over sacrum/coccyx, trochanter, IT, heel and lateral malleoli

10. STATISTICS • 70% occur in people over 65 • Most common sites SACRUM AND HEELS • Shoulder, heel, and ear were the favorite sites of newly developed PrUs

11. EPIC ORDER SET: PRESSURE ULCER PREVENTION

12. STAGES/PROGRESSION4 stages depending on amount and time of ischemia • Hyperemia (redness) will occur within 30 minutes of sustained pressure. If the Pressure is removed the hyperemia will disappearin approximately 24-36 hours • Depending on a number factors (including general health) ischemia begins in 2-6 hours of sustained pressure • Texture usually feels hard • Necrosis begins ~6 hours after sustained pressure. • At this stage skin appears blue or greyish and may be indurated. Recovery at this stage is variable. • Finally, if pressure continues, ulceration occurs.

13. STAGES

15. Pressure Ulcer Staging STAGE 1: Skin is intact and shows a non blanchable, localized redness over a bony prominence. Redness remains after pressure is released. Signs and symptoms may include pain, firm, soft, warm or cool compared to adjacent tissue. – EPIDERMIS STAGE 2:Considered partial thickness wound. Superficial break in the epidermis or partial thickness loss of dermis. Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Bruising indicates suspected deep tissue injury. STAGE 3: Skin break with deep tissue involvement down to subcutaneous layer. Full thickness tissue loss. Subcutaneous fat may be visible. Bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. STAGE 4: Skin break with deep tissue involvement down to the bone, tendon, or muscle. Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Stage 3 and 4 are considered Full Thickness wounds.

16. STAGES

17. Pressure Ulcer Staging • Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. • Suspected Deep Tissue Injury (SDTI): Skin is purple. Level of tissue necrosis is suspected to be deep.

18. *difference between stage II and stage III – stage II will never have slough *Never back stage a PrU; document a “healing stage III” not a “stage II”

19. HEELS • Second most common site for PrU’s, and most common site of DTI • Color reflects the degree of DTI: • Red - hyperemia and ischemia • Purple – infarction • Black - necrosis

20. UNAVOIDABLE PRESSURE ULCERS • According to NPUAP: An individual develops a PrU even thought the provider had evaluated the individual’s clinical condition and pressure ulcer risk factors’ defined and implemented interventions that are consistent with individual needs, goals and recognized standards practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate • “Kennedy Terminal Ulcers”

21. KENNEDY TERMINAL ULCERS • Ulcers that some people get as they are dying • Usually on the sacrum • Usually pear shaped • Colors vary • Irregular borders • Come on suddenly • Geriatric phenomenon

22. KENNEDY TERMINAL ULCERS CONTINUED • Often confused for dirt or dried stool in the beginning, and providers try to wash it off only to find it is under the skin • In the beginning it can look like the skin got scraped off in a bad abrasion • Progresses rapidly (over a matter of hours)

23. KENNEDY TERMINAL ULCER

24. KENNEDY TERMINAL ULCER

25. KENNEDY TERMINAL ULCER

26. DOCUMENTATION FOR UNAVOIDABLE END OF LIFE ULCERS • Complete wound closure may not be realistic goal, wound may improve but due to progressive or irreversible underlying medical condition, complete healing is not expected. • The wound represents an additional body systems failure for a person who is progressing towards death • Patient has been losing weight despite appropriate nutritional interventions • A treatment plan emphasizing minimizing pain and odor related to the dying process • Repeated hospitalizations or ED visits in past 6 months may indicate overall decline or instability *from Clinical Practice Guidelines, American Medical Directors Association, CMS guidelines

27. TIP OF THE ICEBERG MORE TO IT THAN MEETS THE EYE….

28. MUSCLE RESPONSE • Muscle damage is more significant than skin damage because muscle is more sensitive to the effects of ischemia • Pressure is highest where the muscle or fascia contacts the bone • The ulcer starts at the bone-soft tissue interface and extends towards the skin • An ulcer is like an iceberg – has a small visible surface with a more extensive unknown base

29. “Assess the whole person; not just the hole in the person”.~ Gary Sibbold

30. EXTRINSIC FACTORS

31. FRICTION • Rubbing 2 surfaces against another • Friction without pressure causes damage to only the epidermis and upper dermal layer (think sheet burn)

32. SHEAR • Friction + Gravity = Shear • Think elevation of head of bed and person sliding down in bed or sliding down in reclining chair • Shear stretches and tears vessels, which reduces the amount of pressure necessary to cause ischemia and deep tissue injury • Shearing can cause undermining and tunneling *blisters

33. DRYNESS • Stratum corneum normally has 10-15% moisture • When the moisture drops below 10% skin becomes cracked and fissured, compromising barrier function and increasing susceptibly to injury • Lotions/creams that have urea or lactic acid can increase kin surface water-binding capacity • Best to apply immediately after bathing when skin is damp because the creams trap moisture under the skin

34. MOISTURE • 65% Of patients with PrUs are incontinent • If a person is incontinent of feces, the chances of getting a PrU increases by 3X • Continued exposure causes maceration – tissue softening • Exposure to sweat or incontinent brief raises skin pH to 7.1 • Exposure to urine or stool increases pH to 8+

35. Moisture continued… • Acid Mantle of the skin – • A slightly acidic film of the skin that acts as a barrier to bacteria, viruses and other potential contaminants that might penetrate the skin • Skin has a normal pH of 4.5-6.2 • Slightly acidic • Sweat, urine, stool, some soaps are alkaline and decrease the acidity of the skin making it more prone for skin breakdown and dermatitis

36. PERINEAL DERMATITIS • Not to be confused with Pressure Ulcers (but in the presence of friction, sheer or pressure easier to cause tissue damage) • Also called incontinence related dermatitis. • Most common cause of nosocomial diarrhea is C-Diff, second is candida albicans (yeast) • Regular use of absorptive pads or briefs raises the pH of the skin and increases production of perspiration

37. Perineal dermatitis • Candida

38. Candida • Usually treated topically • Remove moisture • Kerlix AMD dressings • Interdry AG (from Coloplast) • Check for other sources of infection – (thrush, vaginitis) which requires oral treatment (diflucan)

39. INTRINSIC FACTORS • Malnutrition and dehydration • Critical illness • Age – thinning of the skin • Low Blood pressure • Tissue Oxygenation • Smoking • Weight loss • Infection • Fever

40. PREVENTION • Risk assessment • Systematic skin assessment • Reduction of risk factors • Patient, family and staff education

41. RISK ASSESSMENT • Braden Scale – • 6 subscales that reflect the degrees of sensory perception, moisture, activity, mobility, nutrition, friction and shear. • Each subscale is rated on a scale according to risk and the scores are totaled • Lower scores mean higher risk for pressure ulcer development

42. POSITIONING • For bed bound patients, perform full position change at least every 2 hours. • Sage Turn and Position Unit

43. 5 PILLOW RULE • Pillow 1 under legs to elevate heels (or Prevelon Heel Protectors) • Pillow 2 between ankles if on side • Pillow 3 between knees if on side • Pillow behind the back (unless you are using the Turn and position unit) • Pillow 5 under the head

44. Do you need to float heels: Can the patient lift their leg off the bed by themselves and hold it a few seconds?

45. RULE OF 30 • Head of bed is elevated no more than 30 degrees and the body is placed in a 30 degree laterally included position when positioned on either side. If the HOB is raised for eating or watching TV, return to original 30 asap • In the 30 degree lateral inclined position, hips and shoulders are tilted to 30 degrees supine position and pillows or foam wedges are used to keep positioned without pressure on the sacrum. Never place directly on trochanter. (Turn and Position Unit)

46. MORE • Use draw sheet and trapeze if possible to decrease friction • Do not position, if possible, over area of break down • NEVER massage reddened areas (this is friction and will increase break down) • Keep in mind heel pads and elbow pads prevent FRICTION not PRESSURE

47. PREVENTION OF FRICTION • Lift sheets • Trapeze • Heel and elbow pads • Moisturizers • Hydration • Transparent dressings • Skin sealants

48. SEATING • Instruct patient to self reposition, if able, every 15 minutes • If patient is unable to independently reposition, place on pressure redistributing cushion and you reposition every hour • Check for bottoming out

49. PREVENTION OF SHEAR • Anti-shear mattress • Lift sheets • HOB 30 degrees • Use pillows or wedges • Use Turn and Position System

50. HAMMOCK EFFECT • Seat sags in the middle. • Needs replaced, placing cushion will not correct • Thighs roll inward, creating pressure on trochanters • Spine slouches, body slides forward causing pressure on the ITs, and shear on the buttocks thighs and spine