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Pressure Area Care

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James Garvey

on 22 October 2012

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Transcript of Pressure Area Care

Care Thank you for your attention! Objectives Risk Factors in Pressure
Ulcer Development Risk Assessment Define the term ‘pressure ulcer’
Describe how they form
List the common sites & risk factors
Describe the four stages of ulcer formation
Identify the common assessment tools
Discuss the principles and practice of pressure area care What is a Pressure Ulcer? A sore caused by constant, unrelieved pressure, sheer or friction to the skin and underlying tissue (Nice, 2003).
Also termed ‘Decubitive Ulcer’ or ‘bed sore’
Can lead to septicaemia or osteomylitis How do Pressure Ulcers form? Pressure slows the blood flow to an area which leads to tissue death
“Friction” and “shear” can add to the problem

Can develop in as little as 1-2 hours

Common occurrence affecting 4-10% of patients admitted to UK hospitals (Nice, 2003) Where do Pressure Ulcers form? Although completely treatable if found early, without medical attention,
bedsores can become life-threatening, and indeed fatal. Christopher Reeve died following sepsis originating
from a pressure related ulcer Some Interesting Stats: - 60% of pressure ulcers develop in hospital (Evans et al, 1995)

- One third of hospitalized patients with pressure sores die during their hospitalization.

- Among those developing a pressure sore in the hospital, more than half will die within the next 12 months. (Revis et al, 2001) Intensity &
Duration of Pressure Tissue
Tolerance Mobility
Chronic or
Terminal Illness
Diabetes Other Risk Factors: Capillary Closing Pressure:

Occurs when pressure applied to the
skin and underlying tissues exceeds
pressures within the capillaries

No blood, no oxygen, tissue dies Extrinsic – failure to recognize risk
inadequate treatment protocols
trauma from patient handling
inadequate hydration
emotional stress
smoking 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.

Make sure the light is sufficient! Patients with Darker Skin For patients 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. What does it mean to "Stage" a pressure ulcer? Pressure ulcers are graded or “staged” to indicate the amount of tissue damage
Stage 1, Stage 2, Stage 3, and Stage 4
Must record as clinical incidents all grade 2+ ulcers Stage 1 Stage 1 is the most superficial, indicated by non blanchable redness that does not
subside after pressure is relieved.
This stage is visually similar to reactive hyperemia (a technical term for excessive
redness) seen in skin after prolonged application of pressure.

Stage I pressure ulcers can be distinguished from reactive hyperemia in two ways: a) reactive hyperemia resolves itself within 3/4 of the time pressure was applied, and b) reactive hyperemia blanches when pressure is applied, whereas a Stage I pressure ulcer does not.
The skin may be hotter or cooler than normal, have an odd texture, or perhaps be painful to the patient.

Although easy to identify on a light-skinned patient, ulcers on darker-skinned individuals may show up as shades of purple or blue in comparison to lighter skin tones. Stage 2 Stage 2 is damage to the epidermis
extending into, but no deeper than,
the dermis.

In this stage, the ulcer may be referred
to as a blister or abrasion. Stage 3 involves the full thickness of the
skin and may extend into the
subcutaneous tissue layer.

This layer has a relatively poor blood
supply and can be difficult to heal.

At this stage, there may be undermining
damage that makes the wound much
larger than it may seem on the surface. Stage 4 is the deepest, extending into
the muscle, tendon or even bone. With higher stages, healing time is prolonged.

While about 75% of Stage II ulcers heal within eight weeks, only 62% of Stage IV pressure ulcers ever heal, and only 52% heal within one year.

It is important to note that pressure ulcers do not regress in stage as they heal.

A pressure ulcer that is becoming shallower with healing is described in terms of its original deepest depth (e.g., healing Stage II pressure ulcer). Most pressure ulcers are preventable
if patient risk is recognized in time for preventive actions to be initiated.
95% are preventable. All patients must be assessed for risk as part of their admission procedure (within 6 hrs, NICE, 2003). Especially for vulnerable patients to target prevention and identify existing pressure sores. This must be documented.

Pressure ulcers usually develop within the first 2 weeks of hospitalization (Langemo et at., 1989)
15% of elderly patients will develop pressure ulcers within the first week of hospitalization (Lyder et al., 2001)

Seniors (>65) and children (<5) are at highest risk
Individuals with SCI are considered high risk Skin Assessment Perfusion
Assess all bony prominences of especially heels, elbow’s, sacrum and buttocks
Special garments, shoes, heel and elbow protectors, stockings, restraints, and protective wear should be removed for skin inspection. Mobility Assessment Immobility is the MOST significant risk factor for pressure ulcer development
Patients who have ANY degree of immobility should be carefully monitored for pressure ulcer development:
Confined to bed, wheelchairs, recliners and couches
Have paralysis or contractures
Wear orthopedic devices that limit function and range of motion
Require assistance in ambulating, moving, turning, repositioning, getting out of bed or chairs Friction & Shearing Assessment Friction: the mechanical force of two surfaces moving across each other; it damages surface tissues, causing blisters and abrasions
Individuals who cannot lift themselves with repositioning are at high risk for friction injuries

Shear: the mechanical force that is parallel rather than perpendicular to the skin, which can damage deep tissue such as muscle
Occurs when the head of the bed is elevated and the individual slides downward (Makelbust & Sieggreen, 2001) Incontinence Assessment Moisture from incontinence contributes to pressure ulcer development by irritating the skin.
Faecal incontinence is a greater risk because the stool contains bacteria and enzymes that are caustic to the skin.
In the presence of both urinary and faecal incontinence, faecal enzymes convert urea to ammonia, raising the skin pH. With a more alkaline skin pH, the skin becomes more permeable to other irritants (Ratcliff & Rodeheaver, 1999).
Patient dignity Moisture Excess moisture can cause maceration, weakening of the skin and eventual skin loss
Cause of excess moisture has to be identified & removed
Chemical irritations
urinary & fecal incontinence
wound drainage
perspiration Mental State Inability to feel and report pain

Lowered mental awareness Risk Assessment Tools Waterlow score
Braden Scale
‘Act as an aid to memory only’ (NICE, 2003) 75-year-old male with heart failure
Alert and oriented
Height 5’9”, Weight 11 stone.
Spends most of the day in bed. Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.
Able to walk a short distance to the chair only with assistance
Incontinent of stool
Continent of urine – uses urinal as needed
Diminished appetite, eats 2 small meals per day. No weight loss
Skin – legs oedematous, no discolouration / breaks Apply Waterlow Score to this patient Braden Risk Assessment Scale Highest possible score is 23, Lowest possible score is 6

Mild risk = 15-18
Moderate risk = 13-14
High risk = 10-12
Very high = <9 When should you check the patient's skin? 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 patient’s skin. Consider patient, surface & medical condition
Encourage patients to shift position /
stand / leg exercises! Education
Bed bound: at least every 2h
Chair-bound: min. 1h. Encourage weight shifts every 15 min. Sitting time< 2hrs in 24 hrs
Must be turned 30 degrees to remove pressure from sacrum, but not onto hip bone
Patients on specialty beds must also be turned.
Use of lifting aids to avoid shearing of skin Respositioning Patients Elevate Heels Ensure space between bed and heels (float heels)
Use pillows to elevate heels off the bed surface (not gloves filled with water)
Do not use doughnuts or sheepskins! Avoid massage of red areas - why? Massage may decrease rather than increase blood flow by damaging the tissues under the skin Head of Bed Elevation Limit time head of bed is elevated to reduce friction and shear
Maintain lowest possible elevation
Avoid more than 30° head-of-bed elevation unless medically needed (NICE, 2001) Incontinence Management - individualized bathing schedule with soap and water to keep skin clean and dry
- Care immediately after soiling
- Apply topical barrier to protect skin
- Indwelling catheters may be used for short periods of time only. Avoid whenever possible as they increase UTI risk
Mattresses & Cushions It is the nurses responsibility to evaluate patients for a specialty bed.
Follow Trust policy
‘Vulnerable patients’ must have a high specification pressure relieving foam mattress as a minimum (Nice, 2003)
‘At risk’ patients must have an air mattress (RCN, 2001)
No seat cushion shown to be better than another (Nice 2003)
Air mattress or cushion
Must still apply principles of PAC
Mattress Types Alternating Pressure Foam Static Air Alternating Air Loss Replacement Mattress Low Air Loss NICE Guidance 2005 The guideline specifies that patients with a grade 1−2
pressure ulcer should:
As a minimum provision be nursed on a high-specification foam mattress (are the ‘norm’ now) / cushion, and
Be closely observed for skin changes or deterioration

Patients with grade 3−4 pressure ulcers should:
As a minimum provision be placed on a high-specification foam mattress with an alternating pressure overlay / or mattress replacement Use a pressure relieving mattress These deliver a 71 % reduction in the risk of developing a pressure ulcer (Cullum et al 2001).
No evidence that high tech pressure relieving devices & overlays are more effective than high specification (low-tech) high specification foam mattresses
Avoid more than 30 head-of-bed elevation unless medically needed Directed Study Were pressure area risk assessment tools / ICP’s were available within your area?
When were these used?
Did you find them easy to understand and did they improve patient care?
How often were patients repositioned?
When pressure sore was detected, what actions were taken?
Where did the pressure sore/s develop?
Why do you think they developed?
Did you locate a pressure sore grading tool?
How was the pressure sore treated?
Which pressure relieving devises were used?
Were these easy to access?
Were they effective?

Will feedback in groups after placement

NICE (2003) Pressure ulcers: the management of pressure ulcers in primary and secondary care. NICE, London
NICE (2003) Guide to Pressure ulcer Prevention. NICE, London
RCN (2001) Guide to Pressure ulcer Risk assessment & Prevention. NICE, London

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