How to Identify & Prevent Pressure Ulcers

TN State Standard 15) Outline the normal structure and function of body systems related specifically to geriatric clientele, and summarize appropriate medical text(s) in order to list signs and symptoms of common diseases and disorders associated with each. Compile a paper or digital artifact describing abnormalities in geriatric patients and what should be reported to a nurse and/or physician for the following: a. Integumentary systems b. Nervous system with eye and ears c. Musculoskeletal systems d. Cardiovascular and respiratory systems e. Digestive and urinary systems f. Endocrine systems

Objective Introduction to pressure ulcers Medical terminology pertinent to pressure ulcers Locate and name the bony prominences associated with positioning for pressure ulcers

The Skin Human body’s largest organ Body’s first line of defense

Functions of the Skin Protection Regulation Sensation Metabolism Communication

Definitions 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.

What is a Pressure Ulcer? A sore caused by constant, unrelieved pressure to the skin and underlying tissue. The pressure comes from outside the body.

How does one form? Pressure slows the blood flow to an area which leads to tissue death “Friction” and “shear” can add to the problem

Where do they form? Pressure ulcers most often form over bony areas on the body

Common places to find a pressure ulcer Bony prominences that are at high risk areas High risk areas include buttocks, tailbone, back of head, hips, heels and ankles Other important sites include: ears, shoulder blades, elbows, mid-back thighs, lower legs, and toes.

What does it mean to “stage” a pressure ulcer? Pressure ulcers are graded or “staged” to indicate the amount of tissue damage Stage 1, Stage 2, Stage 3, and Stage 4

Who is MORE likely to develop a pressure ulcer? There are “Risk Factors” that when present, make a resident MORE likely to develop a pressure ulcer

Risk Factors Poor nutrition-balanced diet needed to nourish skin Residents who cannot eat a healthy diet Poor appetite or unable to tolerate diet Can not feed themselves Poor dental health- Bad Teeth or dentures that do not fit properly or that are not used.

Risk Factors Inability to easily move or reposition Incontinence-moisture Poor Nutrition Residents who cannot eat a healthy diet Poor appetite or unable to tolerate diet Can not feed themselves Poor dental health- Bad Teeth or dentures that do not fit properly or that are not used.

Risk Factors Circulatory Problems-good blood flow is needed to bring oxygen and nutrients to cells Older Persons-thin and fragile skin

Risk Factors Lowered mental awareness-cannot act to prevent pressure ulcers Poor Fluid Balance-Fluid balance is needed for healthy skin Poor Nutrition Residents who cannot eat a healthy diet Poor appetite or unable to tolerate diet Can not feed themselves Poor dental health- Bad Teeth or dentures that do not fit properly or that are not used.

Risk Factors When you see even one or two of these risk factors, be on the lookout. This resident is at greater risk of developing a pressure ulcer. Poor Nutrition Residents who cannot eat a healthy diet Poor appetite or unable to tolerate diet Can not feed themselves Poor dental health- Bad Teeth or dentures that do not fit properly or that are not used.

Bell Work What is difference between sloughing and eschar? What is maceration? What is difference between shearing and friction?

TN State Standard 15) Outline the normal structure and function of body systems related specifically to geriatric clientele, and summarize appropriate medical text(s) in order to list signs and symptoms of common diseases and disorders associated with each. Compile a paper or digital artifact describing abnormalities in geriatric patients and what should be reported to a nurse and/or physician for the following: a. Integumentary systems b. Nervous system with eye and ears c. Musculoskeletal systems d. Cardiovascular and respiratory systems e. Digestive and urinary systems f. Endocrine systems

Daily Objective Review Risks For Pressure Ulcers Work on Braden Scale with partners Identify “blanchable vs. non-blanchable skin”

Braden Scale PATIENT DATA 42 year old female with advanced Multiple Sclerosis admitted to long-term care from home 3 months ago. Height 5�3�, Weight 98 lbs. Contractures of both upper extremities. Right leg contracted. Does not respond to verbal commands. Communicates pain or discomfort by moaning.  Does not move self. Has frequent spastic muscle contractions. Cannot bear own weight. Requires full assist to transfer from bed to chair.  Slips down frequently whenever positioned in chair. Requires maximum assistance for repositioning.  Difficulty swallowing. Oral intake over last week is less than 1/3 of meal. Has lost 10 pounds in the last 30 days. Incontinent of urine and stool for more than one year. Wears incontinent briefs. Dampness of perineal skin is detected every time patient is moved or turned.  Hgb = 9

When to check the skin Every time you change, help to the toilet, dress, bathe, transfer, and/or turn a resident... you have a chance to check and care for a resident’s skin. What does it mean for an area of skin to be non-blanchable?

What to look for on the skin An area of skin that is noticeably different than the surrounding area What does it mean for an area of skin to be non-blanchable? It may look red, and the redness does not “fade” when the skin is touched, and released (blanched).

Residents with darker skin For residents with darker skin, the skin may look darker or lighter than the surrounding skin. Skin may look a little: red, blue, or purple in color. What does it mean for an area of skin to be non-blanchable?

What is “blanchable”? Look for areas of redness that are “non-blanchable*” https://youtu.be/THjmjtDDDoc What does it mean for an area of skin to be non-blanchable? Note: Redness should fade, when the skin is *touched and released.

Another thing to try... Gently feel for a change in skin temperature: it may feel warmer or cooler than the surrounding area. A “suspicious area” may feel "spongy“ or "raised". What does it mean for an area of skin to be non-blanchable?

TN State Standard 15) Outline the normal structure and function of body systems related specifically to geriatric clientele, and summarize appropriate medical text(s) in order to list signs and symptoms of common diseases and disorders associated with each. Compile a paper or digital artifact describing abnormalities in geriatric patients and what should be reported to a nurse and/or physician for the following: a. Integumentary systems b. Nervous system with eye and ears c. Musculoskeletal systems d. Cardiovascular and respiratory systems e. Digestive and urinary systems f. Endocrine systems

Bellwork Review for Quiz Answer this question after quiz What are at least 4 risk factors for pressure ulcers

Daily Objective Be able to list stages of pressure ulcers Be able to stage pressure ulcers based off description and pictures

Stages of Pressure Ulcers https://youtu.be/C189XsIyZk4

Suspected Deep Tissue Injury 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: Painful Mushy, firm, or boggy Warmer or cooler as compared to other tissue National Pressure Ulcer Advisory Panel (2007). For Educational Purposes.

Stage I 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. National Pressure Ulcer Advisory Panel (2007). For Educational Purposes.

Stage II 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: Perineal dermatitis, maceration, tape burns, skin tears or excoriation . Only use to describe An abrasion, a blister, or a shallow crater that involves the epidermis and dermis. National Pressure Ulcer Advisory Panel (2007). For Educational Purposes.

Stage III 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.

Stage IV 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.

Unstageable Involves full-thickness tissue loss. The base of the ulcer is covered by : Slough: yellow, tan, gray, green, or brown OR 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 National Pressure Ulcer Advisory Panel (2007). For Educational Purposes.

Pressure Ulcers on Heels 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

Pressure Ulcers On Ears 1. Pressure on ears from mattress when in the sidelying position 2. Eyeglasses and oxygen tubing

Other Areas for Pressure Ulcers 1. Between abdominal folds 2. The buttocks 3. The thighs 4. Under the breasts

Bell Work—Be prepared to answer these What stage: An area of intact skin that does not blanch and is usually over a bony prominence What stage: A full-thickness wound with tissue loss. The subcutaneous tissue may be visible but muscle, tendon, or bone is not exposed What stage: A superficial partial thickness wound Presents as a shallow, open ulcer without slough and with a red and pink wound bed What stage: Involves Full-Thickness skin loss can visibly see exposed muscle, bone, or tendon

Daily Objective Review Stages of Pressure Ulcers Prevention of Pressure Ulcers and be able to verbalize different measures

TN State Standard 15) Outline the normal structure and function of body systems related specifically to geriatric clientele, and summarize appropriate medical text(s) in order to list signs and symptoms of common diseases and disorders associated with each. Compile a paper or digital artifact describing abnormalities in geriatric patients and what should be reported to a nurse and/or physician for the following: a. Integumentary systems b. Nervous system with eye and ears c. Musculoskeletal systems d. Cardiovascular and respiratory systems e. Digestive and urinary systems f. Endocrine systems

What Stage Pressure Ulcer?

What Stage Pressure Ulcer?

Prevention Skin Care Check the skin on daily basis. Check the skin while performing other care giving tasks Healthy skin is clean and moisturized, not dry, cracked, or scaly.

Prevention Nutrition and eating Repositioning Encourage residents to eat and drink Assist residents with eating Feed residents unable to feed themselves Repositioning Turning Encourage residents to shift position

Prevention Positioning Encourage residents to make small shifts in position Keep head of bed at 30° or less Heels elevated off mattress supported by pillows under the legs Use a pillow to keep the knees and heels from rubbing together Turning Schedule for residents who cannot move by themselves

Tip: Use a pillow After turning or helping a resident shift their weight, use a pillow to support the new position in the bed or chair.

Review Prevention is the key encourage small shifts in weight if the resident is able if a resident is on a turning schedule, be sure to stick to the schedule

Review Prevention is the key care for a resident’s skin (Healthy skin is clean and moisturized, NOT soiled, dry, cracked, or flakey.)

Review Prevention is the key encourage or assist a resident to eat their food and drink their water

Always be on the look-out Review Always be on the look-out check a resident’s skin each time you change, help to the toilet, dress, transfer, bathe, or otherwise have an opportunity.

Always be on the look-out Review Always be on the look-out look for an area of skin that looks noticeably different than the surrounding areas especially on skin over the bony parts of the body

Review You have a great opportunity to positively IMPACT the health and well-being of nursing home residents.

Review If you see even a small change in a resident’s skin – TELL SOMEONE TELL SOMEONE, until you are SURE they hear you.