1. Focus on Pressure Ulcers (Relates to Chapter 13, “Inflammation and Wound Healing,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

2. 2 Pressure Ulcer A localized injury to the skin and/or underlying tissue due to pressure with or without shear/friction Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

3. 3 IncidenceIncidence Most common sites  Sacrum  Heels Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

4. 4 Influencing Factors Amount of pressure (intensity) Length of time pressure is exerted (duration) Ability of tissue to tolerate externally applied pressure Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

5. 5 Contributing Factors Shearing force—Pressure exerted on the skin when it adheres to the bed and the skin layers slide in the direction of body movement Friction—Two surfaces rubbing against each other Excessive moisture Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

6. 6 Risk Factors Advanced age Anemia Contractures Diabetes mellitus Elevated body temperature Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

7. 7 Risk Factors Immobility Impaired circulation Incontinence Low diastolic blood pressure (<60 mm Hg) Mental deterioration Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

8. 8 Risk Factors Neurologic disorders Obesity Pain Prolonged surgery Vascular disease Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

9. 9 Clinical Manifestations Ulcers are graded or staged according to deepest level of tissue damage:  Stage I (minor) to stage IV (severe)  Slough or eschar may have to be removed for accurate staging of some ulcers. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

10. 10 Clinical Manifestations Stage I Intact skin with non-blanchable redness Possible indicators—Skin temperature, tissue consistency, pain Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

11. 11 Clinical Manifestations Stage I May appear with red, blue, or purple hues in darker skin tones Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

12. 12 Clinical Manifestations Stage II Partial-thickness loss of dermis Shallow open ulcer with red pink wound bed Presents as an intact or ruptured serum-filled blister Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

13. 13 Clinical Manifestations Stage III Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

14. 14 Clinical Manifestations Stage III Presents as a deep crater with possible undermining of adjacent tissue Depth of ulcer varies by anatomic location. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

15. 15 Clinical Manifestations Stage IV Full-thickness loss can extend to muscle, bone, or supporting structures.  Bone, tendon, or muscle may be visible or palpable. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

16. 16 Clinical Manifestations Stage IV Undermining and tunneling may also occur. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

17. 17 Clinical Manifestations Infection Signs  Leukocytosis  Fever  Increased ulcer size, odor, or drainage  Necrotic tissue  Pain Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

18. 18 Clinical Manifestations Complications Most common—Recurrence Cellulitis Chronic infection Osteomyelitis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

19. 19 AssessmentAssessment Assess pressure ulcer risk on admission and at periodic intervals based on care setting and patient’s condition. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

20. 20 Assessment Tools Use risk assessment tools such as the Braden scale for systematic skin inspection. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

21. 21 Assessment of Patients With Dark Skin Look for areas of skin darker (purplish, brownish, bluish) than surrounding skin. Use natural or halogen light for accurate assessment (fluorescent light casts a blue color that can skew results). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

22. 22 Assessment of Patients With Dark Skin Assess skin temperature using your hand.  An ulceration may feel warm initially, then become cooler. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

23. 23 Assessment of Patients With Dark Skin Touch the skin to feel its consistency.  Boggy or edematous tissue may indicate a stage I pressure ulcer. Ask about pain or an itchy sensation. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

24. 24 PlanningPlanning Overall goals  No deterioration  Reduce contributing factors  Not develop an infection  Have healing  Have no recurrence Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

25. 25 Prevention – Education Prevention is the best treatment. Identify risk factors and implement prevention strategies. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

26. 26 PreventionPrevention Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

27. 27 Prevention – Skin Care Remove excessive moisture. Avoid massage over bony prominences. Turn every 1 or 2 hours (with care to avoid shearing). Use lift sheets. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

28. 28 Prevention – Skin Care Position with pillows or elbow and heel protectors. Use specialty beds. Cleanse skin if incontinence occurs.  Use pads or briefs that are absorbent. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

29. 29 Prevention – Nutrition Caloric intake elevated to 30 to 35 cal/kg/day or 1.25 to 1.50 g protein/kg/day  Supplements, enteral, or parenteral feedings may be necessary. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

30. 30 Treatment – Ulcer Care Document and describe size, stage, location, exudate, infection, pain, and tissue appearance. Keep ulcer bed moist. Cleanse with nontoxic solutions. Debride. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

31. 31 Treatment – Ulcer Care Use adhesive membrane, ointment, or wound dressing. Verify good nutrition. Teach self-care and signs of breakdown. Initiate specialty services. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

32. 32 Operative Repair Skin grafts Skin flaps Musculocutaneous flaps Free flaps Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

33. Case Study 33 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

34. 34 Case Study 82-year-old woman with hypertension and limited mobility secondary to osteoarthritis and degenerative joint disease She lives alone. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

35. 35 Case Study She stays in bed or sits in recliner. She has little ambulation or few position changes daily. Daughter visits once a day to help with meals and medications. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

36. 36 Case Study Patient started on home health Initial assessment revealed 2 cm × 5 cm stage II ulcer to coccyx. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

37. 37 Case Study Health aide to come 3 times a week to help Nurse to visit once a week to help with medication and ulcer management Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

38. 38 Discussion Questions 1.What is the priority nursing implementation for her? 2.What interventions can help the ulcer heal? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

39. 39 Discussion Questions 3.What can be done to prevent future ulcers? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.