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  1. 1. A Pound of Prevention Maintaining Skin Integrity: Developing a Workable Pressure Ulcer Prevention Plan Tracey J. Siegel MSN RN CWOCN CNE
  2. 2. Objectives: Define revised pressure ulcer stages and definitions. Identify Evidence Based Practices for pressure ulcer prevention. Describe methods to implement pressure ulcer prevention programs in all levels of care. Discuss the role of student nurses in pressure ulcer prevention
  3. 3. Bedsore! Decubitus Ulcer ! Pressure Ulcers!
  4. 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…” Nightingale (letter to family with bed bound child)
  5. 5. The Problem Incidence estimated to be between 1 and 1.7 million annually Half of these are Stage 2 or greater Hospital Prevalence Rate- 3-10% ↑ LOSfor patient with pressure ulcers Cost to treat is estimated to be between 5 and 8.5 billion dollars/year Patients with pressure ulcers require 50% more skilled nursing time 2001- 8,500 pressure ulcer associated deaths! How do we estimate the cost in pain and suffering?
  6. 6. All Pressure Ulcers are the Fault of Poor Nurisng Care! Let's Discuss-Let's Debate
  7. 7. What are Pressure Ulcers? “Any lesion caused by unrelieved pressure resulting in damage of underlying tissue which occur over bony prominences and are staged to classify degree of tissue damage observed.” (AHCPR Guidelines, 1994) “Refers to a group of untoward events associated with skin breakdown over bony prominences.” (Meehan & Hill 2002) Localized wounds that develop over bony prominences due to excessive pressure, which leads to ischemia and necrosis and eventually skin ulceration
  8. 8. Stage I Stage I: 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.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) 2006 NPUAP
  9. 9. Stage I Pressure Ulcer
  10. 10. Stage II Pressure Ulcer 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. 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. *Bruising indicates suspected deep tissue injury
  11. 11. Stage II Pressure Ulcer
  12. 12. Stage III Pressure Ulcer 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. 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 contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
  13. 13. Stage III Pressure Ulcer
  14. 14. Stage IV Pressure Ulcer 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.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.
  15. 15. Stage IV Pressure Ulcer
  16. 16. Unstageable 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.
  17. 17. Unstageable
  18. 18. Deep Tissue Injury 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. 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.
  19. 19. Deep Tissue Injury
  20. 20. Deep Tissue Injury
  21. 21. Deep Tissue Injury Thank you Joan Aumack!
  22. 22. Stage I vs. DTI
  23. 23. Incontinence Associated Dermatitis (IAD) Erythema with or without erosion of the perineal skin Cause: prolonged exposure to stool, urine or perspiration Prevalence and Incidence is estimated to be 20% to 40% of hospitalized patients
  24. 24. IAD
  26. 26. Pathophysiology Contributing Factors: Chemical irritation Bacterial overgrowth Mechanical damage to skin Leads to: Inflammation Erosion Secondary infections ulcerations
  27. 27. Pressure Ulcer Prediction
  28. 28. Pressure Ulcer Prevention Identify individual at risk Daily skin assessment Prevent incontinence skin damage Preserve Skin Integrity Relief of Pressure, Friction & Shear Turning schedules Keeping heels elevated Avoid dragging Keep HOB at 30 or lower Support Surfaces Maintain mobility Maintain adequate nutrition & hydration
  29. 29. Pressure Ulcer Treatment Manage underlying co-morbidities Accurate pressure ulcer assessment Pressure redistribution Nutritional interventions Practice Evidence Based Wound Interventions
  30. 30. Incontinence Associated Dermatitis Prevention and Treatment Prevention: Daily skin assessment Gentle cleansing after incontinence episodes with pH balanced solutions Avoid vigorous cleaning-no rinse solutions Applications of effective moisture barriers Treatment: Accurate assessment is important- don’t confused with pressure ulcer-treatments are different- occlusion is contraindicated!
  31. 31. The Real World Is your loved one suffering from a bedsore? Call 1-800- BEDSORE Operators are standing by!
  32. 32. True or False? Doctor, Mrs. Jones has a hospital acquired pressure ulcer. If the nurses did their jobs- this never would have happened!
  33. 33. Resolved: All Pressure Ulcers are Avoidable! “Most pressure ulcers can be prevented and deterioration at Stage I can be halted.” (2007 National Patient Safety Goals) “The more complex the ulcer by stage, the more likely the experts were to presume poor care was delivered. 42% of respondents considered a Stage IV pressure ulcer evidence of neglect…39% agreed that lawsuits are an appropriate way to stimulate improvement in the quality of nursing home care.” (Brandeis et al 2001)
  34. 34. The Raging Debate “Terry Schiavo was at extremely high risk for developing pressure ulcers yet according to news reports she had none.” “Caregiver commitment, knowledge and accountability play a far greater role in pressure ulcer development than malnutrition, immobility and incontinence…nothing is going to change if we accept the fact that pressure ulcers are inevitable. Until we decide to make a difference and refuse to accept a level of care that is less than what is needed, pressure ulcers will continue to happen.” K. Olshansky MD
  35. 35. Resolved: Some Pressure Ulcers areUnavoidable! “If a patient admitted to a LTC facility develops pneumonia and is admitted to an ICU-how likely will it be that the facility will face a financial penalty? Not likely, although we strive to achieve the best outcomes, it is accepted that clients may develop complications of their illnesses. Now what if a pressure ulcer occurred? Apparently a different standard would apply…the facility would be subject to fines, and malpractice, civil and potentially criminal lawsuits.” R. Salcido MD 2006
  36. 36. Skin Failure? “To admit that not all pressure ulcers are preventable is like confessing to a sin against humanity in a age of rapidly advancing medical technology- a technology that prolongs the dying process and places the patient at risk for diseases of organ failure…lives of extremely low quality are extended by medicines, tubes and machines…Pressure ulcers may be one part of the syndrome of multiple organ failure that accompanies the terminal stages of many diseases. If hearts, lungs and kidneys fail- isn’t it logical that the body’s largest organ would also show signs of failure? Witkowski and Parish 2000
  37. 37. Unavoidable Pressure Ulcer Is the PU indicative of just another organ system failure in a cascade of failures? What was the prognosis prior to the onset of the PU? Did it change thereafter? What was the risk of PU? Were preventive measures compromised due to extenuating circumstances?
  38. 38. How do Regulators Determine? Unavoidable Excellent documentation about prognosis Followed Standard of Care Utilization of Evidence Based Practice Avoidable Documentation incomplete Standard of Care breeched Non evidence based practice
  39. 39. In the News! Currently in NJ- all full thickness nosocomial pressure ulcers are reportable to Dept. of Health and require a root cause analysis- can be fined! As of 2008- Medicare no longer pays hospitals for nosocomial pressure ulcers!
  40. 40. New Jersey Hospital Association Research EBP Works!
  41. 41. What can Student Nurse’s Do? Be Patient Advocates during clinical rotations! Promote the use of evidence based pressure ulcer risk assessment, prevention and treatments!
  42. 42. Questions???
  43. 43. Thank You! A Day in Your Life!