1. Pressure Ulcer Prevention and Management
Dipti Jethani RN BSN
Alverno College
All motion clips/images not labeled obtained from Microsoft Clip Art

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3. Table of Contents Navigation Objectives Incidence Risk Factors
Stages of Ulcers
Prevention
Pathophysiology
Complications
Treatment

4. Learning Objectives
Learner will be able to identify the stages of pressure ulcers
Learner will be able to identify patients at risk for pressure ulcers
Learner will be able to identify 3 ways to decrease risk and incidence of pressure ulcers
Learner will be able to identify 3 complications of pressure ulcers

5. Let’s Start With A Case Study
Grace is an 84 year old female who was recently admitted into the hospital with a diagnosis of Pneumonia.
She has been weak, she used a cane before admittance in the hospital. She now is only mobile per wheel chair.
She also is an uncontrolled Type II Diabetic (Non-Insulin Dependent)
HOW WILL YOU PREVENT HER FROM DEVELOPING PRESSURE ULCERS?
Doheny, Patrick. (2007). Happy planet one. [Photograph]. Retrieved from

6. What Factor Most Puts Grace at Risk for Pressure Ulcers?
Age
Lack of Mobility
Diabetes
Having Pneumonia
Having a cane – she’ll beat the nurses up!
Click Here To Read
Case Study Narrative

7. THAT’ S RIGHT

8. SORRY TRY AGAIN
Although this is a good answer, there is another answer more fitting than this one, try again.

9. THE SKIN Three Layers Epidermis Dermis Subcutaneous Tissue
Outermost Layer
Contains sensory receptors for pain, temp, touch, vibration, and pressure detection
Barrier to preserve moisture, vitamins, minerals, and proteins
Dermis
Lies beneath the epidermis, deeper and thicker too
Contains connective tissue, & sebaceous glands
Contains fat &sweat glands
Subcutaneous Tissue
Layer of fat and connective tissue
Layer of insulation to conserve body heat
National Pressure Ulcer Advisory Panel (2007).
For Educational Purposes.
Lippincott Williams and Wilkins, 2011

10. Let’s Review… What are pressure ulcers??
Also known as: Pressure/Bed Sores
Areas of cellular necrosis and skin breakdown most common over bony prominences
Can occur anywhere on the body
Most Common Sites: Sacrum, Heels
For Educational Purposes, NIH
Lippincott Williams and Wilkins, 2011

11. Incidence of Pressure Ulcers
Estimated: 1 mill/yr; annual cost = $1.6 billion
The elderly account for > 60% of decubitus patients
Since 2008, hospitals are not able to be reimbursed for the care of Stage III or IV pressure ulcers that the patient acquires during their hospital stay
63% increase in hospitalized patients with pressure ulcers between 1993 and 2003
There has been no sig decrease in pressure ulcers in the last 10 years
Most often seen in elderly
Bedridden; Chair Bound
9 out of 10 patients were covered by a government program (Medicare or Medicaid)
In 2007, CMS reported 257,412 cases of preventable pressure ulcers as secondary diagnoses
Anders, 2010; Sage Products Inc (2003)
Mereck Manual of Geriatrics, 2000; Krasner (2008).

12. Risk Factors Extrinsic Factors Intrinsic Factors Pressure Friction
Shearing
Intrinsic Factors
Immobility
Inactivity
Incontinence
Malnutrition
Age
Mental Status
Mereck Manual of Geriatrics, 2000

13. Assessing the Risk BEGINS ON ADMISSION Skin Exam
On admission and every shift
History of Pressure ulcers
Recent weight loss
Mobility Status
Urinary/Bowel Incontinence
Dietary Intake/Nutr Status
Use Scales For Assessment
Braden Scale
Norton Scale
PUSH Tool
Guren, D., 2010.

14. Braden Scale
Used to accurately predict who will develop pressure ulcers
6 Areas of Assessment: Sensory Perception, Activity, Mobility, Skin Moisture, Nutritional Intake, Friction and Shear
Scored from 1-4
1 for low level of functioning and 4 for the highest level or no impairment
Total scores range from 6-23
At Risk (15-18)
Moderate Risk (13-14)
High Risk (10-12)
Very High Risk (9 or below)
Cassell, 2009.

16. Prevention BEGINS AT FIRST CONTACT Turn patient at least every 2 hours
Do not place pts in a 90 degree lateral position
Puts more pressure on greater trochanter and lateral malleolus
Don’t elevate HOB > 30 degrees (except when eating) to minimize shearing forces
Avoid Fluorescent Light, it casts a blue tint to skin (Capezuti, 2008)
Check skin of high risk patients for changes in:
Color, turgor, temp, and sensation.
Mereck Manual of Geriatrics, 2000

17. Prevention Cont. Patient should not sit more than 2 hours
Sitting position puts increased pressure on ischial tuberosities.
Reposition patient every hour in chair
Teach patient to shift weight every 15 minutes
Do not use pillows/ rubber doughnuts
Keep skin surface clean and dry (Meticulous skin care)
As few pads as possible should be used
Main Points:
Keep pressure off the area of breakdown
Clean and dress the wound
Maintain good nutrition
Mereck Manual of Geriatrics, 2000

18. Prevention Monitor Lab Values: HgB <12
Total Lymphocyte Count <1200
Serum Albumin <3.5
Serum Transferrin <170
Promote Movement and Freq Position Changes
Mereck Manual of Geriatrics, 2000
(Anders, 2010)

19. Pressure Relief Aids Lippincott Williams and Wilkins, 2011
Gel Flotation Pads
Sheep Skin
Heel Boots
Low Air Loss Bed
Air-Fluidized Bed
Spanco Mattress
Convoluted Foam Mattress
Alternating Pressure Mattress
Lippincott Williams and Wilkins, 2011

20. Pressure Points Most Develop Over 5 locations: 90% occur in lower body
Sacral Area
Greater Trochanter
Ischial Tuberosity
Heels
Lateral Malleolus
90% occur in lower body
Agency for Health Care Policy and Research (2008)
Lippincott Williams and Wilkins, 2011; Abrass, 2004

21. Case Study
Grace has a history of COPD and has smoked 1 PPD for 22 years, but quit 7 years ago.
Her Diabetes has progressed and due to complications her Left foot was amputated.
On the last shift a small Stage I pressure ulcer was also discovered.

22. What complication should the nurse most focus on preventing?
A. Progression of the Ulcer to a new stage B. Increased Length of Stay C. Infection D. Sepsis E. All of the Above F. A and B only
Click Here To Read
Case Study Narrative

23. Stages of Pressure Ulcers
Staged according to depth of damage
Bright Hub Inc, Public Domain Image
Mereck Manual of Geriatrics, 2000

24. 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.
Abrass, 2004

25. 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.
Abrass, 2004

26. 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.
Abrass, 2004

27. 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.
Abrass, 2004; NPUAP, 2007

28. 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.
Abrass, 2004

29. 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.
Abrass, 2004

30. 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.
Oklahoma Foundation for Medical Quality, 2009

31. Case Study Cont. Which of the following is Grace most at risk for?
Friction
Shearing
Maceration
Laceration
Click Here To Read
Case Study Narrative

32. Case Study Grace became incontinent of bowel and bladder.
Click Here To Read
Case Study Narrative
Grace became incontinent of bowel and bladder.
She has a decreased appetite and has become more confused since the last shift.
A urine specimen was obtained and results show she has a UTI.

33. What measures can you take to prevent progression and development of pressure ulcers?

34. Pathophysiology
Affected area becomes hypoxic and ischemic d/t press exerted on it  Decreased blood flow to site Capillaries Collapse, Thrombosis occurs Tissue Edema/Necrosis Accumulation of waste products at site Tissue Breakdown Cell Death
Lippincott Williams and Wilkins, 2011

35. Stress Response and Pressure Ulcers
Stress occurs  Adrenal Glands produce Epi SNS releases NE NE causes peripheral vasoconstriction Decreased Oxygen Delivery Epi enhances production of chalone Chalone protein depresses regeneration of epidermal tissue Tissue Breakdown Cell Death
Epi = Epinephrine NE = Norepinephrine
Place mouse over chalone to see definition
Maklebust, J., & Sieggreen, M. (2001).

36. Aging Muscle & fat are lost with aging (to spread out press)
Skin Elasticity Decreases
 in ascorbic acid levels:
BVs & Connective tx more fragile
Lowers threshold of pressure injury
 in # of Dermal BVs:
Incr risk of ischemic injury by press and shearing forces
Wound healing ed:
Repair rate declines
Cell proliferation es
Wound tensile strength es
Collagen deposition es
Lippincott Williams and Wilkins, 2011; Mereck Manual of Geriatrics, 2000

37. Inflammation
Damaged BVs  Exposed Collagen With Thrombin exposed collagen stimulates platelet activity Activation, aggregation, and adhesion of platelets and release mediators Stimulates Vasoactive substances Breakdown products attract nuetrophils and macrophages Monocytes become Macrophages Release growth factors Trigger Fibroblasts to secrete collagen & proteins Wound becomes beefy red and bleeds Vasculature begins to restore
Hulse, 2011

38. Genetics Study by Bregstorm & Braden (2002) Certain Medical Conditions
found A.A. lowest risk for Stage I ulcers & Caucasians at highest risk for developing Stage I ulcer
For stages II-IV AA most at risk for progression of an ulcer & Caucasians least at risk
Certain Medical Conditions
Diabetes M.
Peripheral Vascular Dx
Predisposed to developing pressure sores
Capezuti, 2008
Mereck Manual of Geriatrics, 2000

39. 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
Guren, D., 2010.

40. Complications Progression of pressure ulcer Secondary Infections
Ex. Sepsis, Cellulitis
Osteomyelitis Loss of limb from bone involvement
Marjolin’s Ulcer
Squamous cell carcinoma within the ulcer
Increased Length of Stay
Increased Costs
Death
Lippincott Williams and Wilkins, 2011
Mereck Manual of Geriatrics, 2000; Capezuti, 2008

41. Treatment Encourage movement Prevention Strategies Pressure Reduction
Avoiding Friction/ Shearing Forces
Stage III/IV
Debridement of necrotic tissue
Freq Irrigation (2-3x/d)
Dressing of the wound
Encourage movement
Abrass, 2004; Anders, 2010

42. POP QUIZ
Identify the pressure ulcer stage of the following area of skin abnormality .
Public Domain Image obtained from:

43. IF YOU SAID: STAGE III YOU WERE RIGHT!!

44. Nutrition Need adequate intake for wound healing and immune response
Incr protein/caloric intake
Supplement with multi-vitamins (A & C)
Consult with a Dietician
Loss of > 15% of lean body mass interferes with wound healing
Immune Function Loss
=> Incr risk of infection and decr wound healing
Anders, 2010; Maklebust, J., 2001

45. Nursing Implications Krasner, 2008
Diligent assessment and documentation of the condition of the skin of all patients
Use of supplements and feeding assistance devices as needed
ONLY pressure ulcers should be st aged; Wounds of other etiologies:
(venous insufficiency, arterial, diabetic/neuropathic foot ulcers, trauma, etc) should be described as partial or full thickness or other appropriate system of documentation
Pressure ulcers are not staged in a reverse manner
Ex. A Stage IV does not progress to a Stage III, II or I.
The stage remains the same throughout the healing process.
In deeper stages (Stage III and IV) tissue destroyed is replaced by granulation tissue and ultimately scar
Krasner, 2008

46. Documentation Location Size Dressing
Type of irrigation soln, drsg applied
Drainage
Amt, color, odor
Undermining/Tunneling Present
Infection s/s
Character of wound
Presence of slough, granulation tissue, etc
Pressure relieving measures used
Hill Rom Services Inc., 2007

47. CASE STUDY CONT.
What aspect of Grace’s existing condition is the most influencing factor for increasing her risk for pressure ulcers?
Pneumonia/COPD
Diabetes
Venous Insufficiency
Lack of Mobility
None of the Above
All of the Above
Click Here To Read
Case Study Narrative

48. Case Study Conclusions
Press ulcers can increase morbidity and risk for complications
Grace represents a typical patient
Documentation and thorough assessment is a necessity
FOR A VIRTUAL TOUR OF SKIN BREAKDOWN SEE NEXT SLIDE
Doheny, Patrick. (2007). Happy planet one. [Photograph]. Retrieved from /.

49. http://www. youtube. com/watch
(Click here to see video)

50. Did you meet the objectives??
Identify the stages of pressure ulcers
Identify patients at risk for pressure ulcers
Identify 3 ways to decrease risk and incidence of pressure ulcers (prevention)
Identify 3 complications of pressure ulcers
Click the link if you want
to review!

51. TRY AND RUN WITH IT
Questions?

52. References
Abrass, I., Kane, R., Ouslander, J. (2004). Essentials of Clinical Geriatrics. (5th ed.). McGraw Hill-Companies, Inc.Hightstown, NJ.
Agency for Health Care Policy and Research (2008). AHCPR Supported Guide and Guidelines [Internet]. Rockville: MD. Retrieved on April 2, 2011 from
Anders, J., Heinemann, A., Leffmann, C., Leutenegger, M., Profener, F., & Von-Rentein-Kruse, W. (2010). Decubitus Ulcers: Pathophysiology and Primary Prevention. Deutsches Arzteblatt International, 107 (21):
Aurora Health Care (2010). Skin Integrity Alterations Potential/Actual for Adult Inpatients. Milwaukee, WI: Aurora HealthCare.
Bright Hub Inc. (2011). Healing Bedsores. Retrieved on April 2, 2011 from aspx.
Capezuti, E., Fulmer, T., Mezey, M., & Zwicker, D. (2003). Evidenced Based Geriatric Nursing Protocols For Best Practice. (3rd ed). Springer Publishing Co., New York, NY.
Cassell, C. (2009). Pressure Ulcer Assessment: The Braden Scale for Predicting Pressure Ulcer Sore Risk. Health Services Advisory Group.
Guren, D. (2010). Skin is in: positioning your surgical patient matters. Retrieved March 28, 2011 from submit=Video.

53. References Cont
Hill-Rom Services Inc. (2007). Guidelines for staging of pressure ulcers. [Brochure].
Hulse, J. (2011). Skin and Wound Care. Pesi Health Care. [Confrence].
Krasner, D., McNeil, M., & Weir, D. (2008). The Pressure’s On: Getting it Right on Admission. Norcross, GA: Molnlycke Health Care.
Lippincott. (2011). Professional Guide to Pathophysiology (3rd ed.). Lippincott Williams and Wilkins. Ambler, PA.
Maklebust, J., & Sieggreen, M. (2001). Pressure Ulcers: Guidelines for Prevention and Management. (3rd ed.). Ambler, PA. Lipponcott Williams and Wilkins.
Molnlycke Health Care (2007). Mepilex Border Sacrum. [Brochure]. Norcross, GA.
National Pressure Ulcer Advisory Panel. (2007). Pressure Ulcer Category/Staging Illustrations. Retrieved on April 1, 2011 from
Nucleus Medical Media. (2011). Pressure Sores [youtube video] Retreived from embedded#at=61.

54. References Cont.
Oklahoma Foundation for Medical Quality. (2009 ). Appendix A: Glossary – Pressure Ulcer Terms. Retrieved on April 10, 2011 from ndix%20A.pdf .
Porth, C., & Matfin, G. (2009). Pathophysiology Concepts of Altered Health States (p ). Philadelphia, PA: Lippincott Williams & Wilkins.
Sage Products Inc. (2003). What the experts say about the financial implications of pressure ulcers. [Brochure]. Cary, Il.
The Merck Manual of Geriatrics 3rd Edition (2000), (pp ). Whitehouse Station, NJ: Merck Research Laboratories.
US Dept of Health & Human Services, National Institutes of Health (2010). Areas Where Bedsores Occur. [Online Image]. Retrieved on April 1, from /19091.htm.