Pressure Ulcer

Prevention
and
Management

DR. MIRFAT ELKASHIF

All motion clips/images not labeled obtained from Microsoft Clip Art
NEXT SLIDE

PREVIOUS SLIDE

HOME /TABLE OF CONTENTS

LAST SLIDE VIEWED

 Navigation Objectives Incidence

Risk Factors Stages of Ulcers Prevention

Pathophysiology Complications Treatment

 At the end of this lab, the students will be
able to:
 Identify the stages of pressure ulcers
 Identify patients at risk for pressure ulcers
 Identify 3 ways to decrease risk and
incidence of pressure ulcers
 Identify 3 complications of pressure ulcers
 Grace is an 84 year old female who
was recently admitted into the
hospital with a diagnosis of
Pneumonia.
 She has been weak, she used a cane
before admittance in the hospital. She
now is only mobile per wheel chair.
 She also is an uncontrolled Type II
Diabetic (Non-Insulin Dependent)

 HOW WILL YOU PREVENT HER FROM

DEVELOPING PRESSURE ULCERS?
a. Age
b. Lack of Mobility Click Here To Read
Case Study Narrative

c. Diabetes
d. Having Pneumonia
e. Having a cane – she’ll beat the nurses up!
 Three Layers
 Epidermis
 Outermost Layer
 Contains sensory receptors for pain,
temp, touch, vibration, and pressure
detection
 Barrier to preserve moisture, vitamins,
minerals, and proteins
 Dermis
 Lies beneath the epidermis, deeper
and thicker too
 Contains connective tissue, &
sebaceous glands
 Contains fat &sweat glands
 Subcutaneous Tissue
 Layer of fat and connective tissue
 Layer of insulation to conserve body
heat
National Pressure Ulcer Advisory Panel (2007).
Lippincott Williams and Wilkins, 2011 For Educational Purposes.
 Also known as: Pressure/Bed
Sores
 Definition:- Areas of cellular
necrosis and skin breakdown
most common over bony
prominences
 Can occur anywhere on the
body
 Most Common Sites: Sacrum,
Heels
Lippincott Williams and Wilkins, 2011
 Extrinsic Factors
 Pressure
 Friction
 Shearing

 Intrinsic Factors
 Immobility
 Inactivity
 Incontinence
 Malnutrition
 Age
 Mental Status
Mereck Manual of Geriatrics, 2000
 BEGINS ON ADMISSION
 Skin Exam

 On admission and every shift

 History of Pressure ulcers
 Recent weight loss
 Mobility Status
 Urinary/Bowel Incontinence
 Dietary Intake/nutrition Status
 Use Scales For Assessment
 Braden Scale -Norton Scale -PUSH Tool
 •Used to accurately predict who will develop pressure ulcers
•6 Areas of Assessment: Sensory Perception, Activity, Mobility,
Skin Moisture, Nutritional Intake, Friction and Shear

•Scored from 1-4

•1 for low level of functioning and 4 for the highest level or no
impairment
•Total scores range from 6-23

•At Risk (15-18)

•Moderate Risk (13-14)
•High Risk (10-12)
•Very High Risk (9 or below)

Cassell, 2009.
 BEGINS AT FIRST CONTACT
 Turn patient at least every 2 hours
 Do not place patient in a 90 degree lateral position
 Puts more pressure on greater trochanter and

lateral malleolus
 Don’t elevate head of bed > 30 degrees (except
when eating) to minimize shearing forces
 Avoid Fluorescent Light, it casts a blue tint to skin
Check skin of high risk patients for changes in:
 Color, turgor, temperature, and sensation.
 Patient should not sit more than 2 hours
 Sitting position puts increased pressure on ischial tuberosities.
 Reposition patient every hour in chair
 Teach patient to shift weight every 15 minutes
 Do not use pillows/ rubber doughnuts
 Keep skin surface clean and dry (Meticulous skin care)
 As few pads as possible should be used
 Main Points:
 Keep pressure off the area of breakdown
 Clean and dress the wound
 Maintain good nutrition
 Monitor Lab Values:
 HgB <12
 Total Lymphocyte Count <1200
 Serum Albumin <3.5
 Serum Transferrin <170

 Promote Movement and Frequent Position Changes

Mereck Manual of Geriatrics, 2000 (Anders, 2010)

 Gel Flotation
Pads

Alternating
Pressure Sheep Skin
Mattress

Convoluted
Foam Heel Boots
Mattress

Spanco Low Air Loss

Mattress Bed

Air-Fluidized
Bed

Lippincott Williams and Wilkins, 2011

 Most Develop Over 5
locations:
 Sacral Area
 Greater Trochanter
 Ischial Tuberosity
 Heels
 Lateral Malleolus
 90% occur in lower body

Agency for Health Care Policy and Research (2008)

Lippincott Williams and Wilkins, 2011; Abrass, 2004

 Grace has a history of COPD
and has smoked 1 PPD for
22 years, but quit 7 years
ago.
 Her Diabetes has progressed
and due to complications her
Left foot was amputated.
 On the last shift a small
Stage I pressure ulcer was
also discovered.
A. Progression of the Ulcer to a new stage
B. Increased Length of Stay
C. Infection
D. Sepsis Click Here To Read
Case Study Narrative
E. All of the Above
F. A and B only
 

 6 Stages

 Staged according to
depth of damage

Bright Hub Inc, 2011. Public Domain Image

Mereck Manual of Geriatrics, 2000

 Maroon or purple intact skin or a
blood filled blister

 Cause: shearing or pressure on

the underlying soft tissue

 Before discoloration occurs, the

area may be:
 Painful

 Mushy, firm, or boggy

 Warmer or cooler as compared

National Pressure Ulcer Advisory Panel (2007).
to other tissue For Educational Purposes.

Abrass, 2004
 An area of intact skin that does
not blanch and is usually over a
bony prominence.

 NON-BLANCHABLE

 Darkly pigmented skin may not

show blanching but its color may
differ from the surrounding area.

 The area may be painful, firm or

soft, or warmer or cooler when
compared to the surrounding
tissue. National Pressure Ulcer Advisory Panel (2007).
For Educational Purposes.
Abrass, 2004
 A superficial partial thickness wound
 Presents as a shallow, open ulcer
without slough and with a red and pink
wound bed.
 This term shouldn’t be used to
describe:
 Perineal dermatitis, maceration,

tape burns, skin tears or excoriation

.
 Only use to describe
 An abrasion, a blister, or a shallow

crater that involves the epidermis

and dermis.

National Pressure Ulcer Advisory Panel (2007).

For Educational Purposes.
Abrass, 2004
 A full-thickness wound with tissue
loss.
 The subcutaneous tissue may be
visible but muscle, tendon, or
bone is not exposed.
 Slough may be present but it does
not hide the depth of the tissue
loss.
 Undermining and tunneling may
be present.
 Bone/Tendon are NOT visible

National Pressure Ulcer Advisory Panel (2007).

For Educational Purposes.

Abrass, 2004; NPUAP, 2007

 Involves Full-Thickness skin
loss

 Can visibly see exposed

muscle, bone, or tendon

 Eschar and sloughing may be

present as well as
undermining and tunneling
National Pressure Ulcer Advisory Panel (2007).
For Educational Purposes.
Abrass, 2004
 Involves full-thickness tissue loss.

 The base of the ulcer is covered

by:-
 Slough: yellow, tan, gray, green,

or brown OR
 Eschar: tan, brown, or black

 The pressure ulcer cannot be

staged until enough eschar or
slough is removed to expose the National Pressure Ulcer Advisory Panel (2007).
base of the wound For Educational Purposes.

Abrass, 2004
 Friction: Surface damage caused by skin rubbing against
 another surface.
 Shearing: Trauma to skin caused by tissue layers sliding against each
other, results in disruption of blood vessels.
 Maceration: Softening of tissue by soaking in fluids.
 Debridement: Removal of damaged tissue.
 Eschar: Thick, leathery necrotic tissue; damaged tissue.
 Slough: Loose, stringy necrotic tissue
 Undermining: Tissue destruction underlying intact skin
 along wound edges.
 Tunneling: A narrow channel/passageway extending into
 healthy tissue.

Oklahoma Foundation for Medical Quality, 2009

 Which of the following is Grace most at risk
for?
a. Friction
b. Shearing Click Here To Read
Case Study Narrative

c. Maceration
d. Laceration
 Click Here To Read
Case Study Narrative

 Grace became incontinent

of bowel and bladder.
 She has a decreased
appetite and has become
more confused since the
last shift.
 A urine specimen was
obtained and results show
she has a UTI.
Affected area becomes hypoxic and ischemic d/t
press exerted on it

Decreased blood flow to site

Capillaries Collapse, Thrombosis occurs

Tissue Edema/Necrosis

Accumulation of waste products at site

Tissue Breakdown

Cell Death

Lippincott Williams and Wilkins, 2011

 Stress occurs
 Epi = Epinephrine NE = Norepinephrine
Adrenal Glands produce Epi

SNS releases NE

NE causes peripheral vasoconstriction

Decreased Oxygen Delivery

Epi enhances production of chalone

Chalone protein depresses regeneration of epidermal
tissue
 Place mouse over chalone to see
definition
Tissue Breakdown
Maklebust,J., & Sieggreen, M. (2001).
 Muscle & fat are lost with aging (to spread out press)
 Skin Elasticity Decreases
  in ascorbic acid levels:
 BVs & Connective tx more fragile
 Lowers threshold of pressure injury
  in # of Dermal BVs:
 Increased risk of ischemic injury by press and shearing forces
 Wound healing ed:
 Repair rate declines
 Cell proliferation es
 Wound tensile strength es
 Collagen deposition es

Lippincott Williams and Wilkins, 2011; Mereck Manual of Geriatrics, 2000

 Damaged BVs

Exposed Collagen

With Thrombin exposed collagen stimulates platelet activity

Activation, aggregation, and adhesion of platelets and release
mediators

Stimulates Vasoactive substances

Breakdown products attract nuetrophils and macrophages

Monocytes become Macrophages

Release growth factors

Trigger Fibroblasts to secrete collagen & proteins

Wound becomes beefy red and bleeds

Vasculature begins to restore

Hulse, 2011
 Account for 20% of all
pressure ulcers
 Easy to acquire hard to heal
 Pressure relief
 Pillows (floating)

 Heel Protector Boots

 Dressing if necessary

 Foam Pads

Guren, D., 2010.

 Progression of pressure ulcer
 Secondary Infections
 Ex. Sepsis, Cellulitis

 Osteomyelitis Loss of limb from bone

involvement
 Marjolin’s Ulcer
 Squamous cell carcinoma within the

ulcer
 Increased Length of Stay
 Increased Costs
 Death

Lippincott Williams and Wilkins, 2011 Mereck Manual of Geriatrics, 2000; Capezuti, 2008
 Prevention Strategies
 Pressure Reduction
 Avoiding Friction/ Shearing Forces
 Stage III/IV
 Debridement of necrotic tissue

 Freq Irrigation (2-3x/d)

 Dressing of the wound

 Encourage movement

Abrass, 2004; Anders, 2010

Identify the pressure ulcer stage of the following area of skin
abnormality .

Public Domain Image obtained from: http://i.ytimg.com/vi/QvcjH98ipeU/2.jpg

 IF YOU SAID:
STAGE III
YOU WERE RIGHT!!
 Need adequate intake for wound healing and
immune response
 Incr protein/caloric intake

 Supplement with multi-vitamins (A

& C)
 Consult with a Dietician

 Loss of > 15% of lean body mass

interferes with wound healing
 Immune Function Loss
 => Incr risk of infection and decr

wound healing
Anders, 2010; Maklebust, J., 2001
Diligent assessment and documentation of the condition
of the skin of all patients

Use of supplements and feeding assistance devices as

needed

ONLY pressure ulcers should be st aged; Wounds of other

etiologies:
• (venous insufficiency, arterial, diabetic/neuropathic foot ulcers, trauma, etc) should
be described as partial or full thickness or other appropriate system of
documentation

Pressure ulcers are not staged in a reverse manner

•Ex. A Stage IV does not progress to a Stage III, II or I.
•The stage remains the same throughout the healing process.
•In deeper stages (Stage III and IV) tissue destroyed is replaced by granulation tissue and
ultimately scar

Krasner, 2008
 Location
 Size
 Dressing
 Type of irrigation, dressing applied

 Drainage
 Amount , color, odor

 Undermining/Tunneling Present
 Infection s/s
 Character of wound
 Presence of slough, granulation

tissue, etc
 Pressure relieving measures used
Hill Rom Services Inc., 2007
 What aspect of Grace’s existing condition is the
most influencing factor for increasing her risk for
pressure ulcers?
a. Pneumonia/COPD
b. Diabetes Click Here To Read
Case Study Narrative

c. Venous Insufficiency
d. Lack of Mobility
e. None of the Above
f. All of the Above
 Press ulcers can increase
morbidity and risk for
complications
 Grace represents a typical
patient
 Documentation and thorough
assessment is a necessity

 FOR A VIRTUAL TOUR OF SKIN

BREAKDOWN SEE NEXT Doheny, Patrick. (2007). Happy planet one. [Photograph].
SLIDE Retrieved from http://www.flickr.com/photos/14132971@N05/
1449122304/.
http://www.youtube.com/watch?v=Eyuguc7KKC4&feature=play
er_embedded#at=61 (Click here to see video)
 Identify the stages of pressure ulcers
 Identify patients at risk for pressure ulcers
 Identify 3 ways to decrease risk and incidence of
pressure ulcers (prevention)
 Identify 3 complications of pressure ulcers
Questions? Email jethandr@alverno.edu
 Abrass, I., Kane, R., Ouslander, J. (2004). Essentials of Clinical Geriatrics.
(5th ed.). McGraw Hill-Companies, Inc.Hightstown, NJ.
 Agency for Health Care Policy and Research (2008). AHCPR Supported Guide and
Guidelines [Internet]. Rockville: MD. Retrieved on April 2, 2011 from
http://www.ncbi.nlm.nih.gov/books/NBK17977/.
 Anders, J., Heinemann, A., Leffmann, C., Leutenegger, M., Profener, F., &
Von-Rentein-Kruse, W. (2010). Decubitus Ulcers: Pathophysiology
and Primary Prevention. Deutsches Arzteblatt International, 107 (21):
371-82.
 Aurora Health Care (2010). Skin Integrity Alterations Potential/Actual for Adult
Inpatients. Milwaukee, WI: Aurora HealthCare.
 Bright Hub Inc. (2011). Healing Bedsores. Retrieved on April 2, 2011 from
http://www.brighthub.com/health/alternativemedicine/articles/52007.
aspx.
 Capezuti, E., Fulmer, T., Mezey, M., & Zwicker, D. (2003). Evidenced Based
Geriatric Nursing Protocols For Best Practice. (3rd ed). Springer Publishing
Co., New York, NY.
 Cassell, C. (2009). Pressure Ulcer Assessment: The Braden Scale for Predicting
Pressure Ulcer Sore Risk. Health Services Advisory Group.
 Guren, D. (2010). Skin is in: positioning your surgical patient matters. Retrieved
March 28, 2011 from http://uwcne.net/grandrounds/display.asp?ID=48&
submit=Video.
 Hill-Rom Services Inc. (2007). Guidelines for staging of pressure ulcers.
[Brochure].
 Hulse, J. (2011). Skin and Wound Care. Pesi Health Care. [Confrence].
 Krasner, D., McNeil, M., & Weir, D. (2008). The Pressure’s On: Getting it
Right on Admission. Norcross, GA: Molnlycke Health Care.
 Lippincott. (2011). Professional Guide to Pathophysiology (3rd ed.).
Lippincott Williams and Wilkins. Ambler, PA.
 Maklebust, J., & Sieggreen, M. (2001). Pressure Ulcers: Guidelines for
Prevention and Management. (3rd ed.). Ambler, PA. Lipponcott
Williams and Wilkins.
 Molnlycke Health Care (2007). Mepilex Border Sacrum. [Brochure].
Norcross, GA.
 National Pressure Ulcer Advisory Panel. (2007). Pressure Ulcer
Category/Staging Illustrations. Retrieved on April 1, 2011 from
http://www.npuap.org/resources.htm.
 Nucleus Medical Media. (2011). Pressure Sores [youtube video] Retreived from
http://www.youtube.com/watch?v=Eyuguc7KKC4&feature=player_
embedded#at=61.
 Oklahoma Foundation for Medical Quality. (2009 ). Appendix A: Glossary –
Pressure Ulcer Terms. Retrieved on April 10, 2011 from http://
www.ofmq.com/Websites/ofmq/Images/SOS%20PU%20Toolkit/Appe
ndix%20A.pdf .
 Porth, C., & Matfin, G. (2009). Pathophysiology Concepts of Altered Health
States (p. 38-46). Philadelphia, PA: Lippincott Williams & Wilkins.
 Sage Products Inc. (2003). What the experts say about the financial
implications of pressure ulcers. [Brochure]. Cary, Il.
 The Merck Manual of Geriatrics 3rd Edition (2000), (pp. 1317-1322).
Whitehouse Station, NJ: Merck Research Laboratories.
 US Dept of Health & Human Services, National Institutes of Health (2010).
Areas Where Bedsores Occur. [Online Image]. Retrieved on April 1,
2011 from http://www.nlm.nih.gov/medlineplus/ency/imagepages
/19091.htm.