Chapter 34 Pressure Ulcers Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Pressure Ulcers Definitions: Bony prominence —area where the bone sticks out or projects from the flat surface of the body Shear—when layers of the skin rub against each other, or when the skin remains in place and underlying tissues move and stretch and tear underlying capillaries and blood vessels Friction—the rubbing of one surface against another The back of the head, shoulder blades, elbows, hips, spine, sacrum, knee, ankles, heels, and toes are bony prominences. These area are sometimes called pressure points. Shearing causes tissue damage. With friction, the skin is dragged across a surface. Friction is always present with shearing. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Sites Pressure ulcers usually occur over bony prominences (pressure points). These areas bear the weight of the body in a certain position. According to the CMS, the sacrum is the most common site for a pressure ulcer. Other sites include: Heels Ears Areas where medical equipment is attached to skin Areas where skin has contact with skin Pressure from body weight can reduce the blood supply to the area. Pressure on the ear from the mattress when in the side-lying position may cause a pressure ulcer. Eyeglasses and oxygen tubing also can cause pressure on the ears. A urinary catheter can cause pressure and friction on the meatus. Tubes, casts, braces, and other devices can cause pressure on arms, hands, legs, and feet. In obese people, pressure can occur from friction between abdominal folds, legs, buttocks, thighs, and under the breasts. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Common Equipment Sites: Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Persons at Risk Who are our persons at risk for pressure ulcers?: Are bedfast or chairfast Need some or total help in moving Are agitated or have involuntary muscle movements Have urinary or fecal incontinence Are exposed to moisture Have poor nutrition Have poor fluid balance Have lowered mental awareness Have problems sensing pain or pressure Have circulatory problems Are obese or very thin Have a healed pressure ulcer Pressure occurs from lying or sitting in the same position for too long. Coma, paralysis, or a hip fracture increases the risk for pressure ulcers. The person’s movements cause rubbing (friction) against linens and other surfaces. Urine, feces, wound drainage, sweat, and saliva expose the person to moisture, which irritates the skin. Pressure ulcer risk increases when the skin is not healthy. Cells and tissue die when starved of oxygen and nutrients. Review the Focus on Children and Older Persons: Persons at Risk Box on p. 596 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Pressure Ulcer Stages Skin color change remaining after pressure is relieved. Persons with light skin—a reddened bony area Persons with dark skin—skin color differs from surrounding areas The skin may feel warm or cool. The person may complain of pain, burning, tingling, or itching in the area. Some persons do not feel anything unusual. Review Box 34-2 on p. 597 in the Textbook for the description of pressure ulcer stages. Review the Focus on Communication: Pressure Ulcer Stages Box on p. 596 in the Textbook. Review the Focus on Long-Term Care and Home Care: Pressure Ulcer Stages Box on p. 596 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Pressure Ulcer Stages Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Stage 1 Intact skin with redness over a bony prominence. Color does not return to normal when skin is relieved of pressure Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Stage 2 Partial-thickness skin loss-appears as blister or shallow ulcer Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Stage 3 Full thickness tissue loss-skin is gone, subcutaneous fat may be exposed, slough (light colored, soft, moist dead tissue may be present) Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Stage 4 Full-thickness loss with muscle, tendon, and bone exposure. Slough and eschar may be present. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Unstageable Full thickness tissue loss with ulcer covered by slough and or eschar making it unable to stage. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Tunneling Wound continues beneath the skin-Makes staging difficult to determine Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Prevention and Treatment Good nursing care, cleanliness, and skin care are essential. The Joint Commission (TJC) and the CMS require pressure ulcer prevention programs. Prevention includes: Identifying persons at risk-most facilities use a Braden scale-we will do this later Some agencies use symbols or colored stickers as pressure ulcer alerts. Implementing prevention measures for those at risk Support surfaces are used to relieve or reduce pressure. Following the person’s care plan Preventing pressure ulcers is much easier and more cost effective than trying to heal them. Pressure ulcers occur in hospitals, long-term care, and home settings. The nurse assesses the person when he or she is admitted to the agency. The Braden Scale for Predicting Pressure Sore Risk is a popular tool. Existing pressure ulcers are identified. Depending on the person’s condition and risk factors, he or she is assessed daily or weekly. Managing moisture, good nutrition and fluid balance, and relieving pressure are key measures. The measures in Box 34-3 on p. 598 in the Textbook may be part of the person’s care plan to prevent skin breakdown and pressure ulcers. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

What are some basic prevention methods? Bed cradle Heel and elbow protectors Heel and foot elevators Gel mats Eggcrates Special mattress Positioning devices Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Prevention Methods Egg mattress Bedcradle Elbow and heel protectors Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Complications Infection is the most common complication. Colonized—the presence of bacteria on the wound surface or in wound tissue. The person does not have signs and symptoms of an infection. Osteomyelitis—inflammation of the bone and bone marrow. This is a risk if the pressure ulcer is over a bony prominence. The person has severe pain. Pain management is important. Pain may affect movement and activity. Immobility is a risk factor for pressure ulcers. It may delay healing of an existing pressure ulcer. According to the CMS, all Stages 2, 3, and 4 pressure ulcers are colonized with bacteria. For some persons, pain and delayed healing signal an infection. Infection must be diagnosed and treated for the pressure ulcer to heal. With osteomyelitis, the person is treated with bedrest and antibiotics. Surgery may be needed to remove dead bone and tissue. Careful and gentle positioning is needed. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Reporting and Recording A complete head to toe skin assessment should be done on any new resident or any resident returning from a hospital stay Report and record any signs of skin breakdown or pressure ulcers at once. Be specific as possible and describe size as compared to standard object (quarter, dime, etc.) Review the Focus on Communication: Reporting and Recording Box on p. 603 in the Textbook. Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Pressure Ulcer Descriptions Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Braden Risk Assessment Used to evaluate which patients might be at risk for skin breakdown Scored from 0 (high risk) to 23 (low risk) Break up into groups to score your patients The Braden Scale assessment score scale: Very High Risk: Total Score 9 or less High Risk: Total Score 10-12 Moderate Risk: Total Score 13-14 Mild Risk: Total Score 15-18 No Risk: Total Score 19-23 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.