Pressure ulcers Katherine Constable, MSN, CWON Patty Brown, BSN, CWOCN
 
 
Skin Facts <ul><li>Largest organ of the body covers approximately 3000 square inches receives 1/3 circulating blood volume...
Factors <ul><li>Decreased sensation </li></ul><ul><li>Decreased mobility </li></ul><ul><li>Nutritional challenged </li></u...
Assessment <ul><li>VISUAL INSPECTION OF THE TAIL </li></ul>
 
Assessment <ul><li>Conduct skin assessment within 4 hours admission </li></ul><ul><li>Inspect skin daily </li></ul><ul><li...
Perineal Dermatitis <ul><li>Skin problems experience by our patients with wound drainage, fecal and urinary incontinence o...
6 factors identified  <ul><li>Chronic exposure to moisture </li></ul><ul><li>Fecal and urinary incontinence </li></ul><ul>...
 
 
 
 
 
 
Treatment <ul><li>Cleanse area with warm water </li></ul><ul><li>Pat dry and use 3M wipes  </li></ul><ul><li>Use nystatin ...
 
 
 
Scope Of The Problem <ul><li>2.5 million patients treated in acute-care facilities annually. </li></ul><ul><li>Pressure ul...
Pathophysiology <ul><li>Prolong pressure </li></ul><ul><li>Sudden impact </li></ul><ul><li>Shear and friction  </li></ul>
 
Shear <ul><li>Diminishes circulation to tissue and damages tissue and blood vessel integrity </li></ul><ul><li>Skeleton mo...
 
Moisture <ul><li>Speeds up decomposition of tissue. </li></ul><ul><li>Ph balance -> tissue fragility </li></ul><ul><li>Mac...
Nutritional Needs 100% Death (pneumonia) 40% 50% Weakness, pneumonia poor healing, too weak to sit, no healing 30% 20% Imp...
 
Stage I  <ul><li>Intact skin with non-blanchable redness of a localized area usually over a bony prominence.  Darkly pigme...
 
 
 
 
 
 
 
 
 
Stage II  <ul><li>Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without s...
 
 
 
After 3 weeks
 
 
Difference between Stage I and II <ul><li>Stage I </li></ul><ul><li>Red non-blanching </li></ul><ul><li>Skin intact </li><...
Mattress Selection
 
Stage III <ul><li>Full thickness tissue loss.  Subcutaneous fat may be visible but bone, tendon or muscle are not exposed....
 
 
 
 
 
Difference between Stage II and III <ul><li>Stage II </li></ul><ul><li>Partial thickness Shallow crater </li></ul><ul><li>...
Stage IV <ul><li>Full thickness tissue loss with exposed bone, tendon or muscle.  Slough or eschar may be present on some ...
 
 
 
 
 
 
Unstageable <ul><li>Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, gre...
 
 
 
 
 
 
 
(Suspected)  Deep Tissue Injury <ul><li>Purple or maroon localized area of discolored intact skin or blood-filled blister ...
 
 
After 2 weeks
 
 
 
 
After 4 weeks
 
Difference between Stage I and DTI <ul><li>Stage I </li></ul><ul><li>Recovers within 24 hours with pressure relief. </li><...
Practice Time
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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F:\Powerpoints\Pressure Ulcer Presentation Nursing Orientaiton 10 Update

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  • As you know the there is the epidermis, dermis, subcutaneous fat, muscle
  • And do this every 8 hours for the 1 st 24 hours. In ICU it should be each shift. Every patient needs a skin assessment form filled out on them. Take pictures- use a camera with a tape measure only or stick your finger in the picture (for perspective) Surgeons use the 7 days for principle for GI surgery, brain tissue, and myocutaneous flaps If devascularized or failure of anatomosis occur it will happen at that time. tissue and vascular failure will occur during this time.
  • Pressure ulcers have been an area of concern for the last 2000 + years. Skin is “the last a mummified body’s tissue is the last to desiccate.. Accounting for its presence in the body areas of little underlying tissue between bone and skin.” Paget gave lectures on bedsores in 1873 saying “pressure ulcers at times erupt from under intact skin The earliest type of classification was develop in 1955 by Guttman. But Shea in 1975 developed the first well documented staging system used in the United States basing the pressure ulcers on pathology this was used widely in the US until the late 1980’s When the wocn group developed the staging system in 1988. The NPUAP held it first consensus group 1989 and was only used fairly successfully for 18 years but was revised to include darker skin tones. NPUAP has been the leaders in defining and establishing guidelines for Pressure Ulcer protocol. Staging was designed to communicate about the depth of a pressure ulcer..
  • These stats will change since the revision since many other skin “afflictions have been included such as perineal dermatitis, tape tears, According to Lyder 2003, these are the stats currently.
  • The Skin remains in place but the underlying structures slides downward without skin moving. Patients with this type of pressure ulcer the sore will be irregular shaped, develop tunnels and undermining. This includes from stretcher to bed, transferring from bed to wheelchair or pulling someone up to the HOB Shear and friction are used interchangeable but they are not the same! The proper terminology is shear strain - the tissue becomes deformed as the body as the body tries to slide or move on a surface.
  • So what is moisture it is wet skin. This can occur from wound drainage, incontinence of urine or fecal, temperature or perspiration Chemical damage - fecal and urinary incontinence, wound drainage, harsh solutions (betadine or H202) Maceration- water logged skin, Incontinence creates excess moisture and chemical damage. Fecal incontinence adds detrimental effects by exposing the skin to bacteria and enzymes
  • The change was made to further define and clarify the difference of between suspected deep tissue injury and stage I. Remember deep tissue injury and stage I pressure ulcers are different ulcers and the outcomes for each will be different. The treatment may be the same initially. Stage I may be difficult to detect, in individuals with dark skin tones, This person “is at risk” the area is painful Cms will not be paid for hospital acquired pressure ulcers, majority of the patients can be managed by positioning off of area, get them on a support surface
  • The previous stage II definition contained language that included other skin disorders- such as tape burns, perineal dermatitis and other non pressure ulcer injury. The wound bed should be pink or red NO purple or discolored and no slough. I can tell you that several perineal dermatitis and other skin disorders have been added to prevalence rates due to the old definitions.
  • It has been my opinion, if you had a stage III just call it a stage IV under the previous definition but this definition further clarifies the stage III. This again will allow for further accuracy in identification and reporting.
  • The further description gives further clarification for the practitioner on the staging .
  • The addition of this definition makes my heart sing! It further clarifies the definition and furthers classifies what you see when evaluating a patient. The definition is clearer and cleaner than the “work in progress” over the last 5 years.
  • This definition was not in the original staging classification. This type of ulcer has been an unidentified but reported over the years. Most deep tissue injury take 7 days to demarcate, by day 9 to 11 spontaneous skin slippage occurs and 14 to 15 days to form eschar.
  • F:\Powerpoints\Pressure Ulcer Presentation Nursing Orientaiton 10 Update

    1. 1. Pressure ulcers Katherine Constable, MSN, CWON Patty Brown, BSN, CWOCN
    2. 4. Skin Facts <ul><li>Largest organ of the body covers approximately 3000 square inches receives 1/3 circulating blood volume. </li></ul><ul><li>From birth to maturity, the skin will undergo a sevenfold expansion. </li></ul><ul><li>Weighs about 6 pounds </li></ul><ul><li>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 </li></ul><ul><li>This organ is capable of self-generation and can withstand limited mechanical and chemical assault. </li></ul>
    3. 5. Factors <ul><li>Decreased sensation </li></ul><ul><li>Decreased mobility </li></ul><ul><li>Nutritional challenged </li></ul><ul><li>Incontinence of urine and stool </li></ul><ul><li>Decreased perception </li></ul><ul><li>Shear and Friction </li></ul>
    4. 6. Assessment <ul><li>VISUAL INSPECTION OF THE TAIL </li></ul>
    5. 8. Assessment <ul><li>Conduct skin assessment within 4 hours admission </li></ul><ul><li>Inspect skin daily </li></ul><ul><li>Use the 7 day principle </li></ul><ul><li>Use a risk assessment scale Braden </li></ul><ul><li>Note moisture, pressure, shear, friction </li></ul><ul><li>Document </li></ul>
    6. 9. Perineal Dermatitis <ul><li>Skin problems experience by our patients with wound drainage, fecal and urinary incontinence or offending chemical exposure to the perinium causing excoriation, irritation, frequently with satellite lesion (ie yeast). </li></ul>
    7. 10. 6 factors identified <ul><li>Chronic exposure to moisture </li></ul><ul><li>Fecal and urinary incontinence </li></ul><ul><li>Limit amount of pads </li></ul><ul><li>Alkaline ph </li></ul><ul><li>Overgrowth or infection with pathogen </li></ul><ul><li>Friction or shearing </li></ul>
    8. 17. Treatment <ul><li>Cleanse area with warm water </li></ul><ul><li>Pat dry and use 3M wipes </li></ul><ul><li>Use nystatin powder next to skin </li></ul><ul><li>Cover with extra protective cream w/ </li></ul><ul><li>antifungal use q12 hours or prn </li></ul><ul><li>Stop the stooling/urine i.e. butt bag or fecal management system. </li></ul><ul><li>Use dri flows under patient- chux trap body heat! </li></ul><ul><li>Get a low air loss overlay. </li></ul>
    9. 21. Scope Of The Problem <ul><li>2.5 million patients treated in acute-care facilities annually. </li></ul><ul><li>Pressure ulcer incidence range U of L Hospital is 5.3% (compared 7-9%). </li></ul><ul><li>Estimated cost $40,000. </li></ul><ul><li>Treatment cost is estimated $11 billion. </li></ul>
    10. 22. Pathophysiology <ul><li>Prolong pressure </li></ul><ul><li>Sudden impact </li></ul><ul><li>Shear and friction </li></ul>
    11. 24. Shear <ul><li>Diminishes circulation to tissue and damages tissue and blood vessel integrity </li></ul><ul><li>Skeleton moves but the skin remains fixed to the surface </li></ul>
    12. 26. Moisture <ul><li>Speeds up decomposition of tissue. </li></ul><ul><li>Ph balance -> tissue fragility </li></ul><ul><li>Macerated tissue is prone to more erosion. </li></ul><ul><li>Incontinence greater risk of PU. </li></ul>
    13. 27. Nutritional Needs 100% Death (pneumonia) 40% 50% Weakness, pneumonia poor healing, too weak to sit, no healing 30% 20% Impaired immune fx, Increased infection 10% mortality Complications % total weight loss
    14. 29. Stage I <ul><li>Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. </li></ul><ul><li>Further description : The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk). </li></ul>
    15. 39. Stage II <ul><li>Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. </li></ul><ul><li>Further Description: Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. </li></ul>
    16. 43. After 3 weeks
    17. 46. Difference between Stage I and II <ul><li>Stage I </li></ul><ul><li>Red non-blanching </li></ul><ul><li>Skin intact </li></ul><ul><li>Stage II </li></ul><ul><li>Partial thickness Shallow crater </li></ul><ul><li>Fluid filled blister </li></ul>
    18. 47. Mattress Selection
    19. 49. Stage III <ul><li>Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. </li></ul><ul><li>Further Description: 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 and stage III ulcers can be shallow. In contract, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable. </li></ul>
    20. 55. Difference between Stage II and III <ul><li>Stage II </li></ul><ul><li>Partial thickness Shallow crater </li></ul><ul><li>Fluid filled blister </li></ul><ul><li>Stage III </li></ul><ul><li>Full thickness with subq </li></ul><ul><li>Exposure may have undermining and/or tunneling </li></ul>
    21. 56. Stage IV <ul><li>Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. </li></ul><ul><li>Further Description: 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. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. </li></ul>
    22. 63. Unstageable <ul><li>Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. </li></ul><ul><li>Further Description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed. </li></ul>
    23. 71. (Suspected) Deep Tissue Injury <ul><li>Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. </li></ul><ul><li>Further Description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. </li></ul>
    24. 74. After 2 weeks
    25. 79. After 4 weeks
    26. 81. Difference between Stage I and DTI <ul><li>Stage I </li></ul><ul><li>Recovers within 24 hours with pressure relief. </li></ul><ul><li>Red or eggplant color </li></ul><ul><li>Skin intact </li></ul><ul><li>DTI </li></ul><ul><li>Doesn’t recover within 24 hours with pressure relief </li></ul><ul><li>Develops rapidly into Stage II </li></ul><ul><li>Purple/ischemic looking </li></ul>
    27. 82. Practice Time

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