1. Chapter 18: Pressure Ulcers

2. 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.

3. 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

4. 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

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

6. Implications and Prevalence
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)

7. 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 ))
Tissue load management
Maintaining skin health
Nutrition and hydration
Patient and family education

8. 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

9. Pressure Ulcer Management
Classification of pressure ulcers (p )
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)

10. Pressure Ulcers (cont’d)

11. 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.

12. 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.

13. 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.

14. 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

15. 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.

16. 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.