1. SKIN BREAKDOWN: PREVENTION, ASSESSMENT, AND TREATMENT Joseph Nicholas, MD, MPH Assistant Professor of Medicine University of Rochester School of Medicine THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. AGS

2. OBJECTIVES Understand high risk for skin breakdown in older adults and all fracture patients Pathogenesis Prevention Medical implications Cost implications Slide 2

3. PRESSURE ULCER Decubitus  Decumbere — “to lie down”  Cubitum — elbow Described by Paget in 1873  “The risk of bedsores in the old with a fractured neck of femur is chiefly in the first week…” Slide 3

4. EPIDEMIOLOGY Develop in 5%  15% of acute care patients Present in 10%  35% of nursing home patients Develop in up to 20% of geriatric fracture patients (can be as low as 5%) Slide 4

5. HOST FACTORS Immobility Incontinence Malnutrition Poor skin perfusion Altered sensation (neuropathy) Altered sensorium (dementia/delirium) Slide 5

6. EXTERNAL FACTORS Pressure Shearing Friction/tearing Moisture Slide 6

7. COMPLICATIONS Infection Pain Psychosocial decline (depression, social isolation, decline in overall health status) Cost Slide 7

8. Bauer J, Phillips LG. Plast Reconstr Surg. 2008;121(1 suppl):1-10. PATHOGENESIS: PRESSURE Slide 8

9. Haleem S et al. Injury. 2008;39(2):219-223. TIME TO OR IS KEY Slide 9

10. Bass MJ, Phillips LG. Curr Probl Surg. 2007;44(2):101-143. LOCATION Slide 10

11. 'From 'Pressure Ulcers', Joseph E. Grey and Keith G. Harding. British Medical Journal. 2006; Volume 332, Issue 7539: pg.472-475. Copyright 2012 by BMJ Publishing Group. Reprinted with permission. SHEARING IN BED Slide 11

12. FRICTION Slide 12 'From 'Pressure Ulcers', Joseph E. Grey and Keith G. Harding. British Medical Journal. 2006; Volume 332, Issue 7539: pg.472-475. Copyright 2012 by BMJ Publishing Group. Reprinted with permission.

13. PRESSURE POINTS Slide 13 'From 'Pressure Ulcers', Joseph E. Grey and Keith G. Harding. British Medical Journal. 2006; Volume 332, Issue 7539: pg.472-475. Copyright 2012 by BMJ Publishing Group. Reprinted with permission.

14. PRESSURE ULCER STAGING

15. STAGE I: NON-BLANCHABLE ERYTHEMA Slide 15

16. STAGE I: NON-BLANCHABLE ERYTHEMA Slide 16

17. STAGE II: SHALLOW, PINK BED, NO SLOUGH Slide 17

18. STAGE II: SHALLOW, PINK BED, NO SLOUGH Slide 18

19. STAGE III: EXPOSED FAT, SUPPORTING STRUCTURES, FULL-THICKNESS ULCER Slide 19

20. STAGE III: EXPOSED FAT, SUPPORTING STRUCTURES Slide 20

21. STAGE IV: EXPOSED BONE, TENDON, MUSCLE Slide 21

22. STAGE IV: EXPOSED BONE, TENDON, MUSCLE Slide 22

23. UNSTAGEABLE: ESCHAR PRESENT Slide 23

24. DEEP TISSUE INJURY Slide 24

25. PRESSURE ULCERS: APPROACH TO PREVENTION

26. NURSES SHOULD SCORE PATIENTS DAILY Braden Scale (most domains are graded 1  4) Sensory perception Moisture Activity Mobility Nutrition Friction & shear (graded 1  3) Score >18At risk Score  12High risk Slide 26

27. PREVENTION Get patients out of bed Reposition (q2h if high risk, q3  4h otherwise) Inspect/score daily Separate bony prominences with pillow Float/protect elbows and heels Moisturize skin (less friction) Keep skin clean and dry Manage incontinence/absorb moisture (but no Foley) Mattress features Slide 27

28. Houwing RH et al. Clin Nutr. 2003;22(4):401-405. NUTRITION Slide 28

29. TREATMENT Wound care consult Clean — saline Debridement — autolytic/surgical/chemical  Wet-to-dry dressings are non-selective, destroy granulation tissue, and are to be avoided Dressings Surgical evaluation for stage 3 and 4 Antibiotics only if clearly infected (topical vs. systemic) Slide 29

30. OVERVIEW OF DRESSINGS FOR PRESSURE ULCERS (1 of 2) Slide 30

31. OVERVIEW OF DRESSINGS FOR PRESSURE ULCERS (2 of 2) Slide 31

32. CONCLUSIONS Major weapons against pressure ulcers: Time to OR Length of stay Early mobility Relief of pressure (back, buttocks, elbows, heels) Clean, dry skin Nutrition/hydration Skin care consults Slide 32

33. Visit us at: Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics www.americangeriatrics.org THANK YOU FOR YOUR TIME! linkedin.com/company/american-geriatrics- society Slide 33