Pressure Ulcer

Prevention
Rebecca Savage RN BSN WCC

Objectives

Nurse will be able to describe the process of pressure ulcer development

Nurse will be able to summarize wound staging

Nurse will be able to develop treatment plan based on stage of the wound
and hospital protocol.

Pressure Ulcer

Definition: A pressure ulcer is localized injury to the skin and/or underlying

tissue usually over a bony prominence, as a result of pressure, or pressure in
combination with shear.

Risk factors

Primary risk factor is impaired mobility!

Being bedfast, chair fast or a reduction in frequency of movement or ability to

move is usually described as having a mobility limitation.

Other risk factors to consider.

Individuals with an existing pressure ulcer (any stage).

Consider adults & children with medical devices. Medical devices contribute
up to 35% of all hospital-acquired pressure ulcers.

More than 50% of pressure ulcers in children are due to medical devices.

Perfusion and oxygenation

Poor nutritional status

Increased skin moisture (including incontinence, diaphoresis)

Risk Assessment..

A risk assessment should be done on all individuals upon entry to the health
care setting

The aim is to identify those who are at potential risk in order that
individualized preventive interventions can be planned and initiated.

Individuals at risk can develop a pressure ulcer within 2 to 6 hours of the

onset of pressure.

Risk assessment should be completed upon admission and reassess every shift
or with at change in condition.

Risk Assessment
Should

only be used as a tool and should support

not replace clinical judgement.

Braden Scale
For Predicting Pressure Sore Risk

Looks at 6 items:

Sensory Perception

Moisture

Activity

Mobility

Nutrition

Friction and Shear

Comprehensive Skin Assessment

Definition: The process by which the entire skin of every

individual is examined for any abnormalities and requires
looking and touching the skin from head to toe, with a
particular emphasis over bony prominences and under
medical devices.

Purpose/Goal of Skin Assessment

Identify any pressure ulcers that may be present

Determine whether there are any skin-related factors predisposing to

pressure ulcer development

Identify other important skin conditions

Provide data necessary for calculating pressure ulcer incidence and

prevalence.

Goal is to prevent harm

95% of all pressure ulcers are preventable!

Relieve the pressure = reduce the harm

Assessment is key

Inspect Thoroughly

Upon admission

Remove all dressings and clothing to visualize the skin

Assess the wound

Document the findings and describe the wound.

Dont forget

In skin folds

Ischium

Between gluteal cleft

All sides of the feet and ankles

Ears

Heels

Back of head

Under and around all medical devices

Assess during all routine care

Frequency of Skin Assessment

As soon as possible but within eight hours of admission

As part of every risk assessment

Ongoing based on the clinical setting and the individuals degree of risk

Prior to the individuals discharge

Each time the patient is repositioned is an opportunity to conduct brief skin

assessment

Increase the frequency of skin assessments in response to any deterioration in

overall condition.

Assesment tips.

Include the following factors in every skin assessment:

Skin color
* Ensure you have adequate light
* Look for differences between comparable body parts
* Look for paleness, flushing, or cyanosis
* Depress any discolored areas to see if blanchable or not

Skin Temperature

Touch the skin to evaluate if it is warm or cool

Compare symmetrical body parts for differences in skin temperature

Edema

Determine if unilateral or bilateral

Grade edema if pitting noted

Turgor

Resiliency of skin, a reflection of hydration status

Moisture

Touch the skin to see if skin is wet or dry

Determine whether moisture changes are localized or generalized

Incontinence?

Skin Integrity

Look to see if skin is intact without any signs of cracks or openings

Determine whether skin is thick or thin

Identify if any bruising noted

Signs of pruritus, such as excoriations from scratching?

Pain

Pain could be a sign of tissue damage or sign/symptom of infection.

Fact..
Any

person who moves less than once every 11

minutes by turning or off-loading is at risk for skin
breakdown.This risk is doubled if they are
incontinent!

Pressure Ulcer Staging

Stage 1

Nonblanchable Erythema

Injury to epidermis only, skin remains intact

The area may be painful, firm, soft, warmer or cooler as compared to

adjacent tissue

Stage II

Partial thickness skin loss- damage to epidermis, dermis, or both

Shiny or dry shallow open ulcer with a red pink wound bed, without slough or
bruising

Easy way to remember 3 Ps (Pink, partial, and painful)

Stage III

Full thickness skin loss involving epidermis, dermis and into but not through
subcutaneous fat

Slough may be present but does not obscure the depth of tissue loss

May include undermining and tunneling

Stage IV

Full thickness tissue loss involving epidermis, dermis, and subcutaneous fat
with exposed bone, tendon or muscle that is visible or directly palpable

Slough or eschar may be present on some parts of the wound bed. Often
include undermining and tunneling

Unstageable

Depth unknown

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

Suspected Deep Tissue Injury

Depth unknown

Purple or maroon localized area of discolored intact skin or blood-filled

blister due to damage of underlying soft tissue

The tissue may be painful, firm, mushy, boggy, warmer or cooler as compared
to adjacent tissue

Medical Device Related Pressure

Ulcers

Background.
Medical

device related pressure ulcers (MDRPUs)

are pressure ulcers that result from the use of
devices designed and applied for therapeutic
purposes.

Examples of MDRPUs.

Characteristics of MDRPUs..

They tend to progress rapidly, as they often occur over areas with minimal
fatty tissue

70% of MDRPUs occur on the head or neck and are usually not over a bony
prominence.

They are not always preventableexample, CPAP requires a tight seal against
the skin. Most are preventable, but not all.

Patients are 2.4% more likely to develop pressure wound if they develop
MDRPU.

Potential sources include.

Respiratory devices:

Tracheostomy faceplates and securement devices

Masks used to deliver non-invasive positive pressure

Endo/Naso tracheal tubes

Oximeter probes

oxygen tubing/nasal cannulas

Continued

Orthopedic devices:

Cervical collars, halo devices, helmets, external fixators, immobilizers, plaster

casts.

Others foley catheters, surgical drains, central venous and dialysis catheters,
compression stockings and restraints.

Key Factors in Wound Management.

Keep it moist
Keep it warm
Control bacteria
Protect and prevent
Remove non-viable (necrotic/dead) tissue.

General Recommendations

Select a wound dressing based on wound assessment and facility protocols..

References

Black, J. (2014). Use of wound dressings to enhance prevention of pressure

ulcers caused by medical devices. International Wound Journal
39(2),133- 142.

Call, E. (2013). Enhancing pressure ulcer prevention using wound dressing:

what are the modes of action? International Wound Journal 28(3),12-23.

Fry, D. (2013). Patient characteristics and the occurrence of never events.

Advanced Skin and Wound Care 145(2), 148-151.

Reddy, M. (2012). Preventing pressure ulcers: a systematic review. JAMA

296(8) 974-984.

National Pressure Ulcer Advisory Panel (NPUAP). Retrieved from

http://www.npuap.org/pressure-ulcer-incidence-density-as-a-quality-measur
e