Transcript Pressure Ulcers PowerPt.

Chapter 36
Pressure Ulcers
Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.
Pressure Ulcers (Decubitus Ulcers,
Bed Sores, Pressure Sores)
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A pressure ulcer is a localized injury to the
skin and/or underlying tissue.
A pressure ulcer usually occurs over a bony
prominence.
Pressure, shearing, and friction are common
causes.
Pressure occurs when the skin over a bony
area is squeezed between hard surfaces.
Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.
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Friction scrapes the skin, causing an open
area.
Shear is when the skin sticks to a surface
while deeper tissues move downward.
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This occurs when the person slides down in the
bed or chair.
Unavoidable pressure ulcer
Avoidable pressure ulcer
Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.
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CMS has standards about pressure ulcers.
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Nursing centers must evaluate each person’s condition and
pressure ulcer risk factors.
Identify and implement a comprehensive care plan and
measures that meet the resident’s needs and goals.
The care plan must include measure to reduce or remove a
person’s risk factors.
Centers must monitor and evaluate the effect of these
measures and revise measures as needed.
Residents with a pressure ulcer must receive the necessary
treatment and services to promote healing, prevent infection,
and prevent new sores from developing.
Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.
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Risk factors include:
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Breaks in the skin
Poor circulation to an area
Moisture
Dry skin
Irritation by urine and feces
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Persons at risk for pressure ulcers are those who:
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Are bedfast or chairfast
Need some or total help in moving
Are agitated or have involuntary muscle movements
Have loss of bowel or bladder control
Are exposed to moisture
Have poor nutrition or poor fluid balance
Have lowered mental awareness
Have problems sensing pain or pressure
Have circulatory problems
Are older
Are obese or very thin
Refuse care
Have a healed Stage 3 or 4 pressure ulcer
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CMS requires that the person make informed
choices.
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The center and resident must discuss the person’s
condition, treatment options, expected outcomes,
and problems from refusing treatment.
The center must address the person’s concerns
and offer options if a certain treatment is refused.
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Pressure ulcer stages
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Stage 1: The skin is red in persons with light skin. The
skin is red, blue, or purple in persons with dark skin.
Stage 2: Partial-thickness skin loss; it may involve a
blister or shallow ulcer
Stage 3: Full-thickness skin loss; subcutaneous fat
may be exposed. Slough may be present.
Stage 4: Full-thickness tissue loss with muscle, tendon
and bone exposed and damaged. Slough and eschar
may be present.
Unstageable: Full-thickness tissue loss with the ulcer
covered by slough and/or eschar.
Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.
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Pressure ulcer sites
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Pressure ulcers usually occur over bony areas
called pressure points.
Common sites include the sacrum and heel.
The ears also are sites for pressure ulcers.
In obese people, pressure ulcers can occur in
areas where skin has contact with skin.
A pressure ulcer can develop where medical
equipment is attached to the skin for a prolonged
time.
Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.
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Prevention
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Good nursing care, cleanliness, and skin care are essential.
The person at risk for pressure ulcers is placed on a support
surface that reduces or relieves pressure.
TJC and the CMS require pressure ulcer prevention
programs.
CMS requires use of the Resident Assessment Instrument.
Prevention involves identifying persons at risk and
implementing prevention measures for them.
Treatment
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The doctor orders wound care products, drugs, treatments,
and special equipment to promote healing.
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Protective devices are often used to prevent and treat
pressure ulcers.
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Bed cradles
Heel and elbow protectors
Heel and foot elevators
Gel- or fluid-filled pads and cushions
Egg crate–type pads
Special beds
Pillows, trochanter rolls, foot-boards, and other positioning
devices
Report and record any signs of skin breakdown or
pressure ulcers at once.
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Dressings
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The nurse decides what dressing to use.
The wound must be moist enough to promote
healing, but not too moist.
For ulcers with drainage, an absorptive
dressing is used.
Wet-to-dry gauze are sometimes used; they
absorb slough, and it is removed when the
dressing is removed.
Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.
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Complications
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TJC estimates that ~60,000 people die each
year from pressure ulcer complications.
Infection is the most common complication.
According to the CMS, all Stage 2, 3, and 4
pressure ulcers are colonized with bacteria.
Other complications
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Osteomyelitis
Pain
Amputation
Longer nursing center stays
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Reporting and Recording
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Report and record any signs of skin
breakdown at once.
Report and record any signs of pressure
ulcers at once.
Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.
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Quality of Life
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The Omnibus Budget Reconciliation Act of 1987
(OBRA), the CMS, and TJC require a care plan
for each person. It must address correct skin
care.
Residents have the right to care that promotes
healthy skin and prevents skin breakdown and
pressure ulcers.
Everyone must keep the person’s skin healthy.
Follow the person’s care plan.
 Be very careful not to injure the skin during care.
 Treat the person with dignity and respect.
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Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.
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