Pressure Ulcers

Pressure Ulcers

The Skin;

• Human body’s largest organ
• Body’s first line of defense

Functions of the Skin:

• Protection
• Regulation
• Sensation
• Metabolism
• Communication

Where do they form?

STATISTICS

1. 70% occur in people over 65 yrs
2. 2-6 times greater risk of mortality
3. 95%  it occur lower body,   in sacrum(65%) and heal (30%)
4. Shoulder, heel, and ear were the favorite sites of newly developed Pressure ulcer

 How it look clinically?

1. Rounded, crater like shapes with regular edges
2. Over bony prominences, but can take on the shape of the bone
3. Usually dark regular base that do not bleed easily
4. Foul odor from ulcer
5. Warm/swollen skin
6. 6. Fever, weakness, and confusion if infection spread to blood or other areas of body

               

ARE ALL ULCERS PRESSURE ULCERS?

• NO!
• Trauma, skin tears, moisture, arterial, venous, diabetic ulcer. 
• These are often confused with Pressure ulcers.
• Pressure Ulcers are over bony prominences as a result of pressure.
• Do not stage any other ulcer besides pressure ulcers

Factors causing pressure ulcer?

Intrinsic factors:

• Malnutrition and dehydration
• Critical illness
• Bedridden/wheel chair.
• Incontinence
• Age/Fragile skin
• Chronic diseases
• Infection, 0besity
• Smoking

Extrinsic factors:

• Friction
• Shear
• Dryness
• Moisture
• Pressure

Risk Factors

• When you see even one or two of these risk factors, be on the lookout. This resident is at greater risk of developing a pressure ulcer.

What does it mean to “stage” a pressure ulcer?

Pressure ulcers are graded or “staged” to indicate the amount of tissue damage

• Stage-1 Reddened area of skin
• Stage-2 Blister/Open Sore
• Stage-3 Crater (bowl shaped depression on surface)
• Stage-4 Damage to muscle or bone

 

MANAGEMENT PROCESS OF PRESSURE ULCER

1. Risk assessment (RA)
Braden scale

Criteria	Score
	1	2	3	4
1. sensory perception	unresponsive	responsive to pain stimuli	response to verbal  commends	No impairment
2. Moisture	Constantly moist	Often moist but not always	Occasionally moist	Rarely moist
3. Activity	Bed fast	chair fast	Walk  occasionally	Walks frequently
4. Mobility 5. Nutrition	Completely immobile Very poor	Very limited Probably adequate	Slightly limited Adequate	No limitations Excellent
6. friction and shear	Problem	Potential problem	No apparent problem

§       

Interpretation of Braden scale

S.NO	CRITERIA	SCORE
1	VERY HIGH RISK	9 or less
2	HIGH RISK	10-12
3	MODERATE RISK	13-14
4	MILD RISK	15-18
5	NO RISK	19-23

Norton scale

Criteria	Score
	4	3	2	1
Physical condition	Good	Fair	Poor	Very bad
Mental condition	Alert	Apathy	Confused	Stupors
Activity	Ambulant	Walks  with help	Chair bound	Bed fast
Mobility	Full	Slightly impaired	Very limited	Immobilized
Incontinence	None	Occasionally	Usually urinary	Urinary and fecal

>18	LOW RISK
14-18	MEDIUM RISK
10-14	HIGH RISK
<10	VERY HIGH RISK

2. Systematic skin assessment (SSA)

• Every time you change, help to the toilet, dress, bathe, transfer, and/or turn a resident... you have a chance to check and care for a resident’s skin.

What to look for
on the skin

• An area of skin that is noticeably different than the surrounding area
• It may look red, and the redness does not “fade” when the skin is touched, and released (blanched).

Residents with darker skin

For residents with darker skin, the skin may look darker or lighter than the surrounding skin.

Skin may look a little: red, blue, or purple in color.

Another thing to try...

Gently feel for a change in skin temperature: it may feel warmer or cooler than the surrounding area.

A “suspicious area” may feel "spongy“ or "raised".

Tip: Good Lighting

When you check a resident’s skin, be sure to have good lighting.

3. Reduction of risk factors  

Reduction of risk factor

TREATMENT TEAM

Treatment:

Pressure management

1.      Patients who are capable of shifting their weight every 10 minutes should be encouraged to do so.

2.       Reposition every 2 hours in case of bed ridden. After repositioning use a pillow to support the new position in the bed or chair

3.      Patients who are bedbound should be positioned at a 30° angle

4.      Heels elevated off mattress supported by pillows under the legs

5.      Use a pillow to keep the knees and heels from rubbing together

6.      Use draw sheet and trapeze if possible to decrease friction

7.      Do not position, if possible, over area of break  down

8.      NEVER massage reddened areas (this is friction and will increase break down)

9.      Keep in mind heel pads and elbow pads prevent FRICTION not PRESSURE

FIVE PILLOW RULE

1.      Pillow 1 under legs to elevate heels (or Prevelon Heel Protectors)

2.      Pillow 2 between ankles if on side

3.      Pillow 3 between knees if on side

4.      Pillow behind the back (unless you are using the Turn and position unit)

5.      Pillow 5 under the head

Preventive devices:

§  Heel and elbow protectors

§   Cushions (no ring shaped cushions)

§  Pillows

§  Water beds

§  Alternating pressure mattresses

DEVICES TO  PREVENTION OF FRICTION

§  Lift sheets

§  Trapeze

§  Heel and elbow pads

§  Moisturizers

§  Hydration

§  Transparent dressings

§  Skin sealants

DEVICES TO PREVENTION OF SHEAR

§  Anti-shear mattress

§  Lift sheets

§  HOB 30 degrees

§  Use pillows or wedges

§  Use Turn and Position System

2. Cleaning and dressing wound

Stage I (not broken): gently wash it with water and mild soap and pat dry

Stage II (open sore): gently wash it with saline solution each time the dressing is changed

Dressing choice includes: films, gauzes, gels, foams and treated coverings

A combination of dressing may be used

3. Wound debridement

• Surgical debridemen                              

·         2.  Mechanical debridement                                                                    

·         3. Autolytic debridement

·         Enzymatic debridement

4.Other interventions

·         Pain management

·         Antibiotics

·         A healthy diet

·         Management of incontinence

·         Muscle spasm relief

·         Negative pressure therapy (vacuum assisted closure)

5. Surgery

• STAGE III & IV with exudates :  flap reconstruction

COMPLICATIONS

• Sepsis. .
• Cellulitis. 
• Bone and joint infections. 
• Cancer. 

Review

• If you see even a small change in a resident’s skin –
  TELL SOMEONE
  
  TELL SOMEONE, until you are SURE they hear you.
• You have a great opportunity to positively IMPACT the health and well-being of nursing home residents.