1. SKIN ASSESSMENT AND PRESSURE ULCER PREVENTION
Denise Gutwein, MSN, RN, CCRN
ICU Clinical Coordinator
Putnam Community Medical Center

2. Educational Objectives
The learner will be able to:
Describe the best approach to prevention
Identify the major risk factors for developing pressure ulcers
Demonstrate how to use the Braden Scale assessment tool
Select the proper surface for assessment findings
Give an overview of wound care utilizing dressings, irrigation, debridement and/or wound vac appropriate to the characteristics of the pressure ulcer.

3. SKIN FACTS: Largest organ of the body
Covers approximately 3000 square inches
Receives 1/3 circulating blood volume
From birth to maturity, the skin will undergo a sevenfold expansion
Weighs about 6 pounds
1cm of skin has 15 sebaceous glands, 3 yards of blood vessels, 100 sweat glands, 3,000 sensory cells, 4 yards of nerves, 300,000 epidermal cells and 10 hair follicles
Is capable of self-generation
Can withstand limited mechanical and chemical assault

4. Early Pressure Relief:
“I myself think that a few, very small pillows placed here and there and moved about whenever there seems to be pressure are really preferable . . .” Florence Nightingale (letter to family with bed-bound child)

6. What is a Pressure Ulcer ?
Any lesion caused by unrelieved pressure usually over a bony prominence that results in damage to underlying tissue

7. Pressure Ulcer
Begins with unrelieved pressure resulting in damage of underlying tissue.
U.S. Department of Health and Human Services
Agency for Healthcare Research and Policy

8. BEST TREATMENT OPTION
AVOIDANCE!

9. Risk Factors Risk Factors for Pressure Ulcer Development:
Inability to perceive pressure
Incontinence/moisture
Decreased activity level
Inability to reposition
Poor nutritional intake
Friction and shear

10. Etiology Factors Contributing to Pressure Ulcers
Etiologic factors contributing to pressure ulcer occurrence:
Pressure
Shear
Friction
PRESSURE: Squeezing together of soft tissue caused by weight
SHEAR: Shearing forces stretch or tear the blood vessels, reducing the amount of pressure needed to occlude them.
FRICTION: Mechanical force that opposes the movement of one surface across another.

11. Factors affecting Tissue Tolerance
Tissue tolerance factors affecting pressure ulcer development:
Vascular competency
Glycemic control in diabetes mellitus
Body weight/malnutrition
Age

12. FORCES IN PRESSURE ULCER DEVELOPMENT
INTRINSIC
NUTRITION
TISSUE OXYGENATION
COMORBIDTIES
INFECTION
EXTRINSIC
PRESSURE
SHEAR
FRICTION
MACERATION
TEMPERATURE
ERGONOMICS

13. Risk Assessments Using Valid and Reliable Tool
The risk assessment tool selected for LifePoint Hospital’s adult patient population is the Braden Scale
Score the risk assessment Braden Scale
Interpret the significance of the score (high, moderate or low risk levels)
Reassess at frequency defined in policy and with significant changes or transfer to another department (to surgery, for example)

14. Braden Risk Assessment Scale
Braden Risk Assessment Scale (abridged version)
Sensory Perception
1 Completely limited
2 Very limited
3 Slightly limited
4 No impairment
Moisture
1 Constantly moist
2 Very moist
3 Occasionally moist
Activity
1 Bedfast
2 Chairfast
3 Walks Occasionally
4 Walks frequently
Mobility
1 Completely immobile
4 No limitation
Nutrition
1 Very poor
2 Probably inadequate
3 Adequate
4 Excellent
Friction and Shear
1 Problem
2 Potential problem
3 No apparent problem

15. Base the Plan on Patient Needs (subscale scores)
Immobile = reposition q 2 hrs in bed
Inactive = reposition q 1hr in w/c
Incontinent = protect skin from exposure
Malnourished = supplement oral intake
Shearing = keep HOB as low as possible
Limited awareness= assess skin daily

16. Nutritional Screening
Screen for Nutritional Deficits
Provide nutritional support to patients with nutritional risks & pressure ulcer risks
Complete nutritional assessment by the dietician as indicated
Estimation of nutritional requirements
Compare nutrient intake with estimated requirements
Identify best feeding route
Provide nutritional supplements as orders between regular meals in order NOT to influence normal food and fluid intake during regular mealtimes.
Monitor nutritional outcome
Reassess nutrition status when there is a change in the individual’s condition.

17. Conduct a Thorough Skin Assessment
Assess on admission and routinely (Braden Scale or as per P&P)
Document finding and incorporate into plan of care
Assess bony prominences and other areas of exposure to etiologic factors. (Roll patient over to inspect front and back)
Observable indications of tissue ischemia (defined in stages)

18. Pressure ulcer stages Stage 1: epidermis; non-blanching erythema
Stage 2: epidermis/dermis; shallow opening;
blisters
Stage 3: subcutaneous tissue/fascia
Stage 4: fascia + bone, tendon, muscle,
cartilage
Unstageable
Note: stages define level of tissue injury and NOT progression of ulcer development or healing.

19. The Medical History & Physical Exam
History and Physical Exam findings may lead to the diagnosis of pressure ulcer.
The etiology of a wound establishes the type of wound and it’s management. Not all wounds are pressure ulcers
While staging may be performed by other clinicians, the stage documented and determined by the physician constitutes the diagnosis.
Assure staging documented by various clinicians is not contrary to the stage documented by the physician.
The physician is responsible to examine the patient and stage the pressure ulcer. While clinicians may collaborate, the physical exam findings and staging is the responsibility of the physician.

20. Physiological condition affecting nutrition
Nutritional Care
Evaluate appropriate lab data
Albumin normal adult range: mg/dl
Pre-albumin normal adult range: 16 – 42 mg/dl
Hemoglobin
normal adult (Female) range: mg/dl normal adult (Male) range: 14 – 18 mg/dl
Hematocrit
normal adult (Female) range: 37 – 47% normal adult (Male) range 40 – 54%

21. Documentation Documentation should reflect:
Assessment and screening findings
History & physical exam findings, reason for hospitalization, lab & other test results, weight and recent change, nutritional screening results, Braden’s score, stage of decubitus, prior treatment and results.
Description of skin breakdown to include
Location, size in length and width, depth & tissue identified at base of ulcer, exudate, smell, color, firmness/bogginess, tunneling, skin condition at integuma, presence of excar.
Reassessment findings at frequency defined in P&P
Plan of Care: cleansing, positioning, turning, barrier meds, surface chosen for offloading, dressing care/change, other interventions
Interventions as instituted and patient response.
Patient/family education
Consults
Reports to MD with orders received

22. Back to the Basics ALL PATIENTS WILL BE KEPT CLEAN & DRY
Moisture from incontinence contributes to pressure ulcer development by macerating the skin. Fecal incontinence is a greater risk factor for pressure ulcer development than urinary incontinence because the stool contains bacteria and enzymes that are caustic to the skin.

23. Preventive Skin Care Reduce exposure to irritants
Clean immediately after incontinence
Apply skin protectants
Keep linens clean/wrinkle free
Check fit of braces, splints, medical devices (e.g., oxygen tubing, NG tube, stockings) and skin underneath
Maintain environmental humidity
Individualize frequency
Document

24. Positioning Devices Teach individual to reposition using the trapeze
Use lifting devices to move individuals who cannot assist
Place pillows/wedges between knees and ankles

25. Head of Bed Elevation Maintain lowest possible elevation
Avoid more than 30° head-of-bed elevation unless medically needed

26. Side Lying Position Avoid positioning directly on the trochanters
Use the 30° lateral inclined position

27. Elevate Heels Ensure space between bed and heels (float heels)
Use pillows to elevate heels off the bed surface
Avoid hyper-extension of the knees
Check for injury from splints when used for heel elevation

28. No Donuts
Do NOT use plastic rings or donuts for pressure relief as this can cause larger area of tissue injury because of intense pressure along the donut X

29. No Massage Avoid Massage of Red Areas
Massage may decrease rather than increase blood flow

30. Let the skin breathe Incontinence Management
DO:
Use gentle soap or skin cleanser
Apply topical barrier to protect skin
DON’T
Scrub the skin
Use plastic incontinence pads on low air loss beds

31. Reduce Shear & Shearing
Shear diminishes blood supply to skin
Use positioning, transferring & turning techniques to minimize friction/shear injury

32. Support Surfaces
Patients at high risk for the development of a pressure ulcer or those with existing pressure ulcer will need a support surface.

33. Change Support Surfaces
Most pressure reducing devices are more effective than standard hospital mattress

34. Types of Support Surfaces
Category 1
Static overlays and mattresses
Foam, air, gel
Category 2
Alternating pressure and air flotation
Category 3
Air fluidized
Low air loss bed/mattress

35. Support Surfaces in Chairs
If patient spends a prolonged
time in a wheelchair:
Use pressure reducing cushion
Instruct to also relieve pressure with hand
Lifts if possible every 15 minutes
Change chair to tilt/recline for more pressure distribution

36. Assessing Performance of a Support Surface
Bottoming out
Surface totally compressed
Use hand check, should not be able to feel person
Memory in foam
Shape remains
Bunching in gels
Deflation in air filled or leakage of fluid or gel

37. Hand-off communication
Communication to the nurse of new findings is important to discuss in a timely manner.
New areas of redness, maceration or breakdown
Change in incontinence pattern or diarrhea
Odor to wound
Dressing soilage or drainage through dressing
Temperature, low blood pressure and/or lethargic as a
sign of infection
Change of shift hand-off communication:
Status of skin
New areas of redness or breakdown
Last turn position
Changes in the patient condition
Location of decubitus and treatment intervention applied
Pain, temperature, vs abnormalities and lethargy

38. Documentation
THERE MUST BE DOCUMENTATION THAT WE MADE EVERY ATTEMPT TO PREVENT THE PATIENT FROM DEVELOPING A PRESSURE ULCER.
THERE MUST BE DOCUMENTATION THAT WE COMMUNICATE SKIN CARE ISSUES BETWEEN CAREGIVERS
THERE MUST BE DOCUMENTATION THAT WE NOTIFY THE PHYSICIAN OF PATIENTS SKIN ASSESSMENT FINDINGS AND WE RECEIVE ORDERS FOR ANY CARE WE PROVIDE TO THE PATIENT

39. PREVENTION OF MACERATION
KEEP PATIENTS DRY AND CLEAN
DO NOT USE DIAPERS UNLESS THE FAMILY INSISTS. THIS MUST BE DOCUMENTED.
USE CLOTH CHUX
USE PH BALANCED PERINEAL CLEANSER
NOTIFY NURSE TO GET AN ORDER FOR INCONTINENT BARRIER CREAM (CALMOSEPTINE)
MAKE ALL EFFORTS TO CONTINUE HOME BOWEL AND BLADDER PROGRAM

40. PRESSURE ULCER DUE TO MACERATION

41. STAGING

42. Pressure Ulcer Staging
Stage I
Stage I - An observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.

43. Pressure Ulcer Staging
Stage I
Dark Skin

44. Pressure Ulcer Staging
Stage II
Stage 2: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.

45. Pressure Ulcer Staging
Stage II
Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.

46. Pressure Ulcer Staging
Stage II

47. Pressure Ulcer Staging
Stage II

48. Pressure Ulcer Staging
Stage II

49. Pressure Ulcer Staging
Stage III
Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
Stage III - Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue

50. Pressure Ulcer Staging
Stage III
Stage III - Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue

51. Pressure Ulcer Staging
Stage III

52. Pressure Ulcer Staging
Stage IV
Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (ie., tendon, joint, capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers
Stage IV - : Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers

53. Pressure Ulcer Staging
Stage IV

54. Pressure Ulcer Staging
Stage IV

55. Pressure Ulcer Staging
Stage IV
Stage IV - : Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers

56. Pressure Ulcer Staging
Stage IV
Stage IV - : Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers

57. Pressure Ulcer Staging
UNSTAGEABLE

58. Venous Ulcers Due to venous insufficiency Medial Aspect of the leg
Beefy Red
Jagged
Painless
Treat with compression

59. Venous Ulcers

60. Venous Ulcers

61. Diabetic Ulcer

62. SKIN TEARS

63. SKIN TEARS

65. Remember . . . Even on a rough day, someone is having a day that is worse!
The End
The End

66. THE END