Chapter 18: Pressure Ulcers

Learning Objectives Describe the etiology of pressure ulcers. Discuss the implications and relevance of pressure ulcers. Classify pressure ulcers using the staging system. Identify key components of pressure ulcer prevention and management.

Learning Objectives (cont’d) List the components of assessment of skin and wounds. Describe critical factors in wound management. Develop a care plan for potential/impaired skin integrity

Etiology “A pressure ulcer is 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. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated” −NPUAP

Etiology (cont’d) Most common pressure ulcer sites have less soft tissue between the bone and skin Coccyx Sacrum Ischial Tuberosity Trochanter Calcaneus

Implications and Prevalence 1993-2006 pressure ulcer hospitalizations increased 80% These hospitalizations are longer and more expensive Prevalence = number of patients with pressure ulcers in a given population at a given time Pressure ulcers considered indicator of quality of care: CMS Never Event (P. 652)

Pressure Ulcer Prevention Assessment Braden Scale for Pressure Ulcer Risk Assessment (Box 18-1, p. 653) Interventions for the Prevention of Pressure Ulcers (Box 18-3, p. 658-659)) Tissue load management Maintaining skin health Nutrition and hydration Patient and family education

Preventing Pressure Ulcers Use lifting devices – do not dragging Change position every 2 hours Do not use donut ring Use pillows at ankles or calf to prevent heel PU Good nutrition- ^protein, fluid, calorie Daily inspection Do not massage at bony areas Keep skin clean Patting not rubbing while dressing change Do not touch trochanter area when positioning side Use talcum powder on the board while transferring

Pressure Ulcer Management Classification of pressure ulcers (p. 660-661) Category/Stage I: Non-blanchable redness of intact skin Category/Stage II: Partial thickness skin loss or blister (loss of dermis, shallow open ulcer) Category/Stage III: Full thickness skin loss (subcutaneous fat visible, bone/muscles are not exposed) Category/Stage IV: Full thickness tissue loss (muscle/bone visible) Additional USA categories Unstageable/Unclassified: Full thickness skin or tissue loss—depth unknown Suspected Deep Tissue Injury-depth unknown (DTI)

Pressure Ulcers (cont’d)

Question Assessment and monitoring Should include onset, location, staging (classification), measurement, exudate description, wound bed characteristics, pain, condition of surrounding tissue, and any undermining or tunneling factors.

Pressure Ulcer Management Assessment and monitoring Should include onset, location, staging (classification), measurement, exudate description, wound bed characteristics, pain, condition of surrounding tissue, and any undermining or tunneling factors.

Pressure Ulcer Management Treatment modalities (Box 18-5, p.665) Guidelines for pressure ulcer treatment Cleanse the wound with a noncytotoxic cleanser (saline) during each dressing change. If necrotic tissue or slough is present, consider the use of high-pressure irrigation. Debride necrotic tissue. Do not debride dry, black eschar on heels. Perform wound care using topical dressings determined by wound and availability. Choose dressings that provide a moist wound environment, keep the skin surrounding the ulcer dry, control exudates, and eliminate dead space. Reassess the wound with each dressing change to determine whether treatment plan modifications are needed. Identify and manage wound infections. Clients with stage III and IV ulcers that do not respond to conservative therapy-surgical intervention.

Pressure Ulcer Management Critical factors Nutrition Nutrition essential for wound healing Lab results associated with poor nutrition Serum albumin <3.5 g/dl Serum transferrin <200 Prealbumin <11 mg/dl Cholesterol <160 Lymphocytopenia 1,500 (100 indicates severe malnutrition) Pain Infection

Pressure Ulcer Management Special Populations Obese patients Skin integrity Palliative care/hospice Preventing wound deterioration or healing wound - not realistic goals Encourage comfort and prompt symptom management The focus of Tx is management of symptoms such as odor, exudate, pain, infection, and bleeding.

Summary Pressure ulcers are a global health concern commonly encountered in both hospital and community settings Pressure ulcers are considered an avoidable, costly complication caused by unrelieved pressure and inappropriate care. Preventing and managing pressure ulcers requires a comprehensive, multidisciplinary plan.