Transcript Professional Work Presentation

PRESSURE ULCERS
Early Detection of Pressure Ulcers
Susan Mutua
University of Central Florida
The Audience
This education program was
designed for the caregiver
who spends the most time at
the patient’s bedside . . .
“The Nursing Assistant”
Objectives
A. The learner will identify the cause of pressure
ulcers.
B. The learner will identify factors that contribute
to the development of a pressure ulcer.
C. The learner will identify the role of the Nursing
Assistant in prevention of pressure ulcers.
The Patient’s Skin
• Largest organ in the body, equals
12-15% of body weight and receives one
third of the body’s circulating blood volume
• Functions
– Protection
– Thermoregulation
– Sensation
– Metabolism
Maintaining Skin Integrity
• Is everyone’s responsibility
• Patient’s first line of defense from infection
• Many forms of skin integrity issues
– Bruises, skin tears, cracks, shearing,
erosions, scratches, blisters, pressure ulcers
– Hospital or Nursing Home acquired pressure
ulcers are of great concern
What is a Pressure Ulcer?
• Any injury caused by unrelieved pressure
that damages the skin and underlying
tissue (fat, muscle, bone). Also called
decubitus ulcers, pressure sores or bed
sores
• Severity ranges from reddening of skin to
deep craters extending to muscle and bone
Why are Pressure Ulcers a Problem?
• Pressure ulcers can produce poor
outcomes for patients including loss of a
limb or even death
• Pressure ulcers are costly
– Increased length of stay
– Added hospital costs
– Additional recovery time
– Pain
– Potential for litigation
Risk Factors
• Moist skin
– Perspiration
– Incontinence
– Wound drainage
• Limited activity and mobility
• Inability to change position independently
in bed or in chair
• Assistance required to get out of bed
• Assistance required to walk
Risk Factors
Loss of sensory perception
– Paralysis (loss of voluntary motion and/or
sensation)
– Neuropathy (“pins & needles” sensation in
affected limb, decrease in sensation)
– Decrease in mental awareness (dementia)
Risk Factors
• Altered blood flow
– Decreased flow of blood to extremities
• Vascular patients
• Diabetic patients
– Edema
– Hypotensive episode (low BP)
Risk Factors
• Friction and Shearing
– Friction – abrasion of the top layer of skin
– Shearing – the skin separating from
underlying tissues
Risk Factors
• Poor nutrition
• Poor hydration
What Does a Pressure Ulcer Look Like?
What Does a Pressure Ulcer Look Like?
• There are four stages of
pressure ulcer plus unstageable
– Stage I: the ulcer appears as a
defined area of persistent redness
in lightly pigmented skin, whereas
in darker skin tones, the ulcer may
appear with persistent red, blue, or
purple hues
Special Consideration for
Pigmented Skin
• Check skin compared to an adjacent
or opposite area on the body
– Skin temperature (warmth or coolness)
– Tissue consistency (firm or boggy feel)
– Sensation (pain or itching)
What Does a Pressure Ulcer Look Like?
• Stage II: ulcer is superficial and
presents clinically as an abrasion,
blister or shallow crater
• Stage III: full thickness of skin is
lost, exposing the subcutaneous
tissue
• Stage IV: full thickness of skin and
subcutaneous tissue is lost,
exposing muscle or bone
What Does a Pressure Ulcer Look Like?
Unstageable: ulcer is covered with
dead tissue which may be black,
brown or yellow
What Can You Do to Prevent
Pressure Ulcers?
• Each person plays an important role
• Communication and timely reporting is critical
• Other resources are also available such as the
patient’s family and friends
• However, it is the “Nursing Assistant” who
spends the most time with the patient and who
can make the biggest difference in preventing
pressure ulcers
Prevention: Decrease Excessive Moisture
• Good skin care
– Bathe patient daily paying particular
attention to skin folds and perineal tissues
– Use skin cleansers with a low pH and skin
protectant on all incontinent patients and
patients who use a bedpan
– Place absorbent material between the skin
folds of obese patients
Prevention: Decrease Moisture
• Good Skin Care
– Limit use of diapers to patients who are out of
bed or who have large amounts of urine or
diarrhea at one time
– Check incontinent patients frequently
– Discuss a toileting schedule with the nurse
– Avoid plastic barriers and sheepskin
– Communicate any signs of redness to nurse
Prevention
Sensory Perception
– Inspect patient’s skin for areas of redness
with every position change
– Avoid massaging or rubbing bony
prominences (Use a gentle touch when
cleansing skin and applying ointments)
– Turn and reposition every two hours
(minimum)
– Elevate heels off of bed surface
– Check position of foot in the heel protection
device and reposition as necessary
Prevention
Sensory Perception
• Remove TED hose at bedtime and check
heels.
• If patient is at risk for heel breakdown, check
more frequently
• Perform active and passive range of motion
(ROM) of all involved extremities
Prevention: Activity/Mobility
• Encourage patient to change position
frequently or turn and reposition
patient every two hours
• If patient is not moving because of
poor pain control, discuss with the
nurse
• Promote ambulation at regular
intervals (consider PT consult if
patient has difficulty with mobility)
Prevention: Activity/Mobility
• Out of bed to chair no longer than two hours at
one sitting
• Reposition in chair after one hour. If patient is
able to do so, remind to shift position every 15
minutes
Hint: Suggest that position be shifted each time there is a
commercial on TV
• Use chair cushion if patient is at risk
Prevention: Altered Circulation
• Report the following unexpected changes
to the nurse:
– Change in vital signs and color
– Change in temperature of skin surfaces
– Decrease in urine output
– Swelling in any body tissues
Prevention: Altered Circulation
• Keep in mind that patients with altered
circulation are susceptible to skin damage
from heat and cold from items such as:
– Heating pads
– Hot packs
– Cold packs
Prevention: Friction/Shearing
• Use moisturizers on dry skin surfaces where
applicable
• Assess need for assistive devices (heel
protectors, extra pillows)
• Use turning and transfer aids (i.e., lift sheets,
hoyer lift)
Prevention: Friction/Shearing
• Prevent shearing by maintaining bed
at 30 degrees or less, unless patient medical
condition requires bed elevation
• When using lift sheet to move patient to top of
bed
• Avoid dragging any part of patient’s body
– Put socks on patient’s feet
– Ask patient to bend knees and to push
against bed surface
Prevention: Friction/Shearing
• Do not leave the patient in the bedpan for
long periods
• Pad patient’s buttocks and or transfer board
when getting patient in and out of bed with
transfer board
• Use elbow protectors when indicated
• Maintain proper positioning in chair
Prevention: Nutrition & Hydration
• Monitor weight on admission and weekly
• Monitor fluid status, I & O as appropriate
• Monitor/encourage nutritional intake
recommendations (target: meal completion
over 75%)
• Accurately record calorie counts
• Give patient nutritional supplements as
ordered
Prevention: Nutrition & Hydration
• Provide patient with hand wipes before
and after meals. Also provide opportunity
to brush teeth
• Whenever possible, get patient out of bed
for meals
• Comfort Rounds!!
PREVENTION is key!
Review
Now let’s test your
knowledge
Select the true statement
A. A pressure ulcer is a surgical wound.
B. A patient with poor circulation is not at
risk for developing a pressure ulcer.
C. Pressure ulcers are caused by
unrelieved pressure.
D. No one develops a pressure ulcer at my
hospital.
Select the true statement
A. A patient with reduced sensation in his
feet is at risk for developing a heel ulcer.
B. Good nutrition leads to bedsores.
C. Moist skin due to perspiration is not a
risk factor.
D. A patient who is paralyzed is not at risk
for developing a pressure sore.
Select the true statement
A. I really don’t worry about pressure ulcers,
that’s the nurse’s job.
B. All patient’s have red heels.
C. I report any reddened area to the RN.
D. I check my incontinent patients every
four hours.
Select the true statement
A. I do not need to report every red mark
that my patient gets on his skin to the
RN.
B. The RN is the only one who can prevent
pressure ulcers.
C. A little pressure sore on my patient’s foot
is not very important.
D. It takes team work to prevent pressure
ulcers and I’m a key player on that team.
Answer Key
C. Pressure ulcers are caused by
unrelieved pressure.
A. A patient with reduced sensation in his
feet is at risk for developing a heel ulcer.
C. I report any reddened area to the RN.
D. It takes team work to prevent pressure
ulcers and I’m a key player on that team.
References
Ayello EA, Baranski S, Lyder CH, Cuddingan J. Pressure ulcers. In:Baranski S
and Ayello EA. Wound Care Essentials: Practice Principles. Springhouse, PA:
Lippincott Williams & Wilkins: 2004. p 240-70.
Balcavage C. Nurse I See Red…Maintaining Skin Integrity, It Can Be Done! 2005
Lehigh Valley Hospital ppt
Calianno C, Assessing and preventing Pressure Ulcers. Adv Skin Wound Care;
2000; 13(5):244-246.
Hess CT. Skin Care Basics..Adv Skin Wound Care 2000; 13(3):127-129.
Panel on the Prediction and Prevention of Pressure Ulcers in Adults. Pressure
Ulcers in Adults:Prediction and Prevention. Cliical PracticeGuideline,No.3
AHCPR Publication No.
92-0047. Rockville,MD:Agency for Health Care Policy and Research; May 1992.
Ratcliff CR,WOCN’s Evidence-Based Pressure Ulcer Guideline. Adv Skin Wound
Care 2005; 18(4):204-207.
Zulkowski,KM, Tellez R, van Rijswijk L. Documentation with MDS Section M: Skin
Condition. Adv Skin Wound Care 2001; 14(2):81-89.