1. Keri Holmes-Maybank, MD Medical University of South Carolina

2.  Supported by the Reynolds Foundation  Improve the quality of geriatric education of residents  Improve quality of care and life for older adults  4 year project  Assessing Care of Vulnerable Elders “ACOVE”  Inpatient and outpatient  3 month blocks  Falls, vision, dementia/delirium/depression, pain

3.  60 years and older

4. Faculty  Pam Pride, MD  Theresa Cuoco, MD  William Moran, MD  Pam Srinivas, RN, MSN, CWOCN  Vanessa Clark, RD, LD Resident Champions  Temeia Martin, MD  Rachel Wolfe, MD  Aundrea Loftley, MD

6.  2.5 million hospitalized patients/yr  60,000 die/yr from pressure ulcer complications ◦ 1 in 25 if pressure ulcer reason for admit ◦ 1 in 8 if pressure ulcer secondary diagnosis  10-18% acute care patients  0.4-38% acute care new ulcers

7.  80% increase pressure ulcer related hospitalizations 1993-2006  Length of Stay 13-14 days (average LOS 5 days)  $9.2-15.6 billion in 2008  1999-2002 awards avg $13.5 million  $312 million in one case

8.  Reduces quality of life  Interfere with basic activities of daily living  Increased pain  Decrease functional ability  Infection – OM and septicemia  Increase length of stay  Premature mortality  Deformity

11.  IMPROVE Task Force ◦ Magnet status ◦ 3 different fines ◦ CATTS ◦ Letter if not documented by MD ◦ Committee if developed in house ◦ Starting order set generated by nurses ◦ MD will certify agree with ulcer stage

12.  Assess patients for existing pressure ulcers.  Appropriately stage Pressure Ulcers using the National Pressure Ulcer Advisory Panel staging criteria.  Identify at risk patients and perform assessment - Braden Scale.

13.  Localized injury to the skin and/or underlying tissue  0ver a bony prominence  Result of pressure, or pressure in combination with shear.

14.  Pressure is the force that is applied perpendicular to the surface of the skin.  Compresses underlying tissue and small blood vessels hindering blood flow and nutrient supply.  Tissues become ischemic and are damaged or die.

15.  Shear occurs when one layer of tissue slides horizontally over another, deforming adipose and muscle tissue, and disrupting blood flow.  Ex: when the head of the bed is raised > 30 degrees.

16.  Occiput  Ear  Scapula  Spinous Process  Shoulder  Elbow  Iliac Crest  Sacrum/Coccyx  Ischial Tuberosity  Trochanter  Knee  Malleolus  Heel  Toe

18.  Any skin surface subjected to excess pressure ◦ Oxygen tubing ◦ Drainage tubing ◦ Casts ◦ Cervical collars

19.  Bed bound individuals form a pressure ulcer in as little as 1-2 hours.  Those in chairs may form a pressure ulcer in even less times because of greater relative force on skin.

20.  Expert panels recommend use of risk assessment tools.  Tool is better than clinical judgment alone.  Scores are predictive of pressure ulcer formation.  Patients with a risk assessment have better documentation and more likely to have prevention initiated.  Braden Scale

21.  Limited ability to reposition self in bed or chair ◦ Stroke with residual deficits ◦ Post-surgical ◦ Paraplegic ◦ Quadraplegic ◦ Wheelchair bound ◦ Bed bound

22.  Sensory perception  Moisture  Activity - degree of physical activity  Mobility – ability to change body position  Nutrition  Friction and Shear

24.  Ability to respond meaningfully to pressure- related discomfort.  Completely Limited ◦ No moan/flinch, cannot feel pain most of body  Very Limited – ◦ Responds only to pain, cannot feel pain ½ body  Slightly Limited – ◦ Responds to command, cannot feel pain 1-2 limbs  No Impairment

25.  Degree to which skin is exposed to moisture.  Constantly Moist  Very Moist ◦ Often but not always, change sheets each shift  Occasionally Moist ◦ Extra linen change a day  Rarely Moist ◦ Only routine linen change

26.  Degree of physical activity.  Bedfast  Chairfast ◦ Assisted into chair, cannot or barely walk  Walks Occasionally ◦ Very short distance, most shift in bed  Walks Frequently ◦ Walks outside room or in room every 2 hours

27.  Ability to change and control body position.  Completely Immobile  Very Limited ◦ Unable to make frequent or significant changes  Slightly Limited ◦ Makes frequent but small changes  No Limitation

28.  Usual food intake pattern.  Very Poor ◦ 1/3 meal, <2 servings protein, NPO w IVF  Probably Inadequate ◦ ½ meal, 3 servings protein, poor tube feeds  Adequate ◦ >1/2 meals, 4 servings protein, supps, TF or TPN  Excellent

29.  Sliding, rubbing against sheets, bed, chair, etc.  Problem ◦ Mod-max assist, slides, cannot move without slide against sheets, spasticity, contractures, agitation  Potential Problem ◦ Feeble, min assist, occ slides, indep moves with slide  No Apparent Problem

30.  Braden Scale score of 18 or less initiate prevention.  Score of 1 or 2 initiate specialty bed.

32.  Partial thickness wound involves ONLY the epidermis and dermis – Stage II.  Full thickness wound involves the epidermis and dermis and extends into deeper tissues (subcutaneous fat, muscle) – Stages III and IV.

33.  The ulcer appears as a defined area of redness that does not blanch (become pale) under applied light pressure – Stage I.

34.  Tissue destruction underneath intact skin at the wound edge.  Wound edges are not attached to the wound base.  Edges overhang the periphery of the wound.  Pressure ulcer may be larger in area under the skin surface.

36.  Tunnel is a narrow channel of tissue loss that can extend in any direction away from the wound through soft tissue and muscle.  Tunnel may result in dead space which can complicate wound healing.  Depth of the tunnel can be measured using a cotton-tipped applicator or gloved finger.

39.  INTACT SKIN.  NON-BLANCHABLE redness of a localized area.  Difficult to detect in individuals with dark skin tones - affected site is deeper in color.  Surrounding skin will feel different than effected area.  May indicate “at risk” persons.

42.  Partial thickness loss of dermis presenting as shallow open ulcer with a RED-PINK wound bed.  Shiny or dry shallow ulcer.  No slough or bruising.  BLISTER - intact, open or ruptured serum or serosangineous-filled.  Tissue surrounding the areas of epidermal loss are erythemic.

45.  FULL-THICKNESS tissue loss.  Subcutaneous fat may be visible.  Bone, tendon, or muscle is NOT visible or directly palpable.  Slough may be present but does NOT obscure the depth of tissue loss.  May include undermining and tunneling.

46.  The depth of a Stage III pressure ulcer varies by anatomical location.  The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue so Stage III ulcers can be shallow.  Areas of significant adiposity can develop extremely deep Stage III pressure ulcers.

49.  FULL-THICKNESS tissue loss.  BONE, TENDON, or MUSCLE is visible or directly palpable.  Slough or eschar may be present but does NOT obscure wound bed.  Often includes undermining and tunneling.  Can extend into supporting structures (fascia, tendon or joint capsule) making osteomyelitis or osteitis likely.

50.  The depth of a Stage IV pressure ulcer varies by anatomical location.  The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow.

53.  FULL-THICKNESS tissue loss in which SLOUGH (yellow, tan, gray, green, or brown), ESCHAR (tan, brown, or black), or both COVER the base of the ulcer.  Cannot determine true depth of wound secondary to slough and/or eschar.  Will be either a Stage III or IV.

56.  INTACT SKIN.  PURPLE or MAROON.  BLOOD FILLED BLISTER.  May be difficult to detect in individuals with dark skin tones.  Color and mechanical stiffness of the skin (firm, mushy, boggy) assist in differentiating between DTI and a Stage I pressure ulcer.

57.  Most common: ◦ Sacrum, buttocks and heels.  Heel may look like a bruise or a blood blister.  1% resolve spontaneously.  Evolution: ◦ Thin blister over a dark wound bed. ◦ Covered by thin eschar. ◦ May rapidly evolve. ◦ Likely become a Stage III or IV.

59.  Skin Tears  Venous Ulcers  Arterial Ulcers  Diabetic Ulcers  Perineal (Incontinence Associated) Dermatitis

60.  Separation of epidermis from the dermis or epidermis and dermis from underlying tissue.  Thin skin, less elastic, purpura or ecchymosis.  Epidermal flap.

61.  Impaired arterial flow to the lower leg and foot.  Tissue ischemia, necrosis and loss  WELL DEFINED MARGINS  Toes, foot, malleolus  Thin, shiny skin, cool skin temperature, decreased or absent hair  Painful - increase with elevation  Decreased pulse  Minimal exudate  Pale wound bed; necrotic tissue

62.  Decrease in blood return from leg and foot.  Between the knee and the ankle.  Thickened, brown discolored skin is noted around the lower calf, ankle and proximal foot.  Skin proximal and distal to the wound is reddened.

63.  Ulcer that occurs in diabetics  Metatarsal head, top of toes, and foot  Neuropathy, poor microvascular circulation  Repetitive trauma, unperceived pressure, or friction/shear  Regular wound margins  Callus around wound  Dry, cracked, warm

64.  Skin irritation from incontinence.  Erosion of epidermis and dermis from mechanical injury to macerated skin.  Buttocks, perineum, and upper thighs.  Secondary infection.  Diffuse erythema.  Scaling, papule and vesicle formation.  Tissue “weeping”.

68.  Identify patients for nutrition consult  Identify reversible causes of undernutrition  WHO classification for Malnutrition  Association between undernutrition and pressure ulcers

69.  3 rd leading condition in hospitalized elders.  55-61% prevalence of in hospitalized elders.  Increased length of stay.  Predictor for early mortality.  Increased morbidity.  Nutritional depletion occurs in 27% admitted elders.

70.  No universally accepted definition.  “Pure protein and energy deficiency”  Severe protein-calorie malnutrition alters tissue regeneration, inflammatory reaction, immune function.

71.  Immune deficiency  Pressure ulcers  Anemia  Falls  Cognitive deficits - DELIRIUM  Infection  Sepsis  Decreased maximal breathing capacity

72.  Weight loss  >65 yo  Vomit 3 days/month  Surgery  Congestive heart failure  Recurrent cough  Current smoking  Social Isolation  Poverty  Low caloric intake  Cognitive impairment  Thyroid dysfunction  Diabetes  Cancer  Depression  Medications  Poor dentition Depression - most common treatable medical cause of anorexia in the elderly.

73.  Decreased appetite ◦ Digoxin, amiodarone, spironolactone ◦ Interferon ◦ Lithium, amitriptyline, SSRI ◦ Most antibiotics, metronidazole ◦ Iron ◦ NSAIDs, colchicine, theophylline  Increase metabolism ◦ Theophylline, thyroxine, pseudoephedrine  Malabsorption ◦ Laxative ◦ Cholestyramine ◦ MTX ◦ Colchicine

74.  Dental status (dentition, gum health)  Food security (poverty)  Food-related functional status (ability to feed, prepare meals)  Appetite and intake (Rx, anorexia of aging)  Swallowing ability  Dietary restrictions

75.  Prealbumin  Albumin

76.  2-3 day half-life.  TRENDING for improvement or worsening of nutrition.  Monitor intervention success.  Initial value not indicative of overall nutritional status.  Should be low with a pressure ulcer.  Affected by infection, liver disease, steroids.

77.  Risk levelPrealbumin level  Normal 15.0 to 35.0 mg/dL  Increased risk 11.0 to 15.0 mg/dL  Significant risk 5.0 to 10.9 mg/dL  Poor Prognosis <5.0 mg/dL

78.  In pressure ulcer with infection prealbumin is inadequate: ◦ Weight ◦ Intake ◦ Tolerance ◦ Hydration status

79.  18-20 day half-life.  Better for baseline assessment.  Not reflective of nutritional status in setting of acute illness.  Lowered even with adequate protein intake in infection, acute stress, surgery, cortisone excess, hydration status.  Cytokines pull albumin from vascular space.

80. It’s always the Cytokines!!!

81. Classification Albumin Mild Malnutrition3.5-3.2 g/dL Moderate Malnutrition3.1-2.5 g/dL Severe Malnutrition<2.5 g/dL

82.  Reversible risk factor for pressure ulcer development  ***Early detection***  Agency for Healthcare Research and Quality ◦ Nutrition assessment ◦ Manage the nutritional needs  National Pressure Ulcer Advisory Panel and European Pressure Ulcer Avisory Panel ◦ Screen and assess for malnutrition – nutri consult ◦ Screen and assess for pressure ulcers – nutri consult

83.  Strong association but no causal relationship.  Twice as many malnourished patients develop pressure ulcers.  17% pressure ulcer risk is food/fluid intake.  Braden  Inadequate calorie intake associated with pressure ulcer formation.

84.  At risk for pressure ulcers - increase calories and protein  Losing weight – increase calories  1.5 to 2 g per kg protein a day  Prostat  Remove dietary restrictions if possible  Vitamin C

85.  Energy requirements are greater  Increase calories and protein consumption  Stage III – Juven - additional arginine and glutamine  MVI  Vitamin C  Zinc 220 mg 2-3 weeks (copper absorption)  Fluids for insensible losses  Give calorie supplements between meals

86.  Low albumin ◦ Presence ◦ Severity ◦ Healing

87.  Calories  Protein  Fluid

88.  Stage II or greater pressure ulcer  Weight loss  Albumin <3.5 g/dL  Order prealbumin and albumin  Assess for reversible risk factors

90.  Assess for pressure ulcers.  Stage Pressure Ulcers - NPUAP staging criteria.  Identify at risk patients and perform risk assessment - Braden Scale.  Identify patients appropriate for nutrition consult.  Reversible causes of undernutrition.  WHO classification for Malnutrition.  Association between undernutrition and pressure ulcers.

92.  1. Normal nutrition  2. Mild malnutrition  3. Moderate malnutrition  4. Severe malnutrition  5. Cannot classify based on the information

93.  BMI  Weight loss  Pressure ulcer  Poverty  Poor Dentition

94. 1. Staging pressure ulcers 2. Assessing risk for pressure ulcer development 3. Assessing for malnutrition 4. Classifying diabetic ulcers

95.  The sacralcoccyxgeal ulcer measures 6.5 cm in width and 8 cm in length.  Eschar completely covers the wound base. This is a: 1. Stage I pressure ulcer 2. Stage II pressure ulcer 3. Stage III pressure ulcer 4. Stage IV pressure ulcer 5. Deep tissue injury 6. Unstageable 7. Skin Tear 8. Diabetic ulcer

96.  Eschar completely covers the wound base.

97.  A reddened area is seen on the left heel.  Skin color remains unchanged after pressure is removed.  The skin surface is unbroken.  No blisters This is a: 1. Stage I pressure ulcer 2. Stage II pressure ulcer 3. Stage III pressure ulcer 4. Stage IV pressure ulcer 5. Deep tissue injury 6. Unstageable 7. Skin tear 8. Diabetic ulcer

98.  Red  Intact Skin  Non-Blanchable

99.  An area of deep maroon discolored skin is located over the sacrum.  The area looks bruised.  Skin surface intact. This is a: 1. Stage I pressure ulcer 2. Stage II pressure ulcer 3. Stage III pressure ulcer 4. Stage IV pressure ulcer 5. Deep tissue injury 6. Unstageable 7. Skin tear 8. Diabetic ulcer

100.  Deep maroon.  Looks bruised.  Skin intact.

101.  46 yo diabetic male with 2 day old ulcer.  On bottom of foot.  2 cm x 2.5 cm.  Callous around edge.  Wound base is visible. This is a: 1. Stage I pressure ulcer 2. Stage II pressure ulcer 3. Stage III pressure ulcer 4. Stage IV pressure ulcer 5. Deep tissue injury 6. Unstageable 7. Skin tear 8. Diabetic ulcer

102.  Diabetic  Foot

103.  Skin over the coccyx is reddened.  Several intact serum blisters are located within the reddened area of skin. This is a: 1. Stage I pressure ulcer 2. Stage II pressure ulcer 3. Stage III pressure ulcer 4. Stage IV pressure ulcer 5. Deep tissue injury 6. Unstageable 7. Skin tear 8. Diabetic ulcer

104.  Intact serum blisters.  Reddened skin.

105.  Pressure ulcer over the sacrum has exposed muscle tissue.  Slough is present on parts of the wound bed.  Undermining of the wound edge also is noted. This is a: 1. Stage I pressure ulcer 2. Stage II pressure ulcer 3. Stage III pressure ulcer 4. Stage IV pressure ulcer 5. Deep tissue injury 6. Unstageable 7. Skin tear 8. Diabetic ulcer

106.  Exposed muscle tissue.  Slough does NOT obscure wound bed.  Undermining.

107.  Loss of epidermal and dermal layers exposes the underlying subcutaneous tissue.  No tendon, bone or muscle is visualized.  The wound base is visible.  No tunneling is noted. This is a: 1. Stage I pressure ulcer 2. Stage II pressure ulcer 3. Stage III pressure ulcer 4. Stage IV pressure ulcer 5. Deep tissue injury 6. Unstageable 7. Skin tear 8. Diabetic ulcer

108.  Epidermal and dermal layers exposes the underlying subcutaneous tissue.  Wound base is visible.  No tendon, bone or muscle.

109.  Very thin skin.  Multiple areas of loss on the forearms.  Appears to have flaps.  Epidermis removed from dermis. This is a: 1. Stage I pressure ulcer 2. Stage II pressure ulcer 3. Stage III pressure ulcer 4. Stage IV pressure ulcer 5. Deep tissue injury 6. Unstageable 7. Skin ulcer 8. Diabetic ulcer

110.  Thin skin.  Torn by tape.  Flap.  Epidermis removed from dermis.

112.  > 60

114.  National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. (2009). Prevention and treatment of pressure ulcers: Clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel. http://www.npuap.org  https://www.nursingquality.org https://www.nursingquality.org  Bernstein L, Bachman TE, Meguid M, Ament M, Baumgartner T, Kinosian B, et al. Measurement of visceral protein status in assessing protein and energy malnutrition: standard of care. Prealbumin in Nutritional Care Consensus Group. Nutrition 1995;11:170.  Dorner B, Posthauer ME, Thomas D. The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. 2009.  Reuben D. Quality Indicator for the Care of Undernutrition in Vulnerable Elders. JAGS. 55:S438-S442, 2007.

115.  Panel for the Prediction and Prevention of Pressure Ulcers in Adults. Prediction and Prevention. Rockville MD. Agency for Health Care Policy and Research. 1992. May. AHCPR Clinical Practice Guidelines, No. 3.  Thomas DR. Improving Outcome of Pressure Ulcers with Nutritional Interventions: A Review of the Evidence. Nutrition. 17:121-125, 2001.  Morley JE. Anorexia or aging: physiologic and pathologic. Am J Clin Nutr 66:760-773, 1997.  Bates-Jensen BM, MacLean CH. Quality Indicators for the Care of Pressure Ulcers in Vulnerable Elders. JAGS 55:S409-S416, 2007.