Lesson 4: Pressure Ulcers Flashcards
Pressure Ulcers
localized area of tissue injury/ necrosis that develops when soft tissue is compressed between a firm surface and underlying bony prominence
What are pressure ulcers a result of?
pressure, or pressure in combination with shear and/or friction.
Who is at greatest risk for a pressure ulcer?
Individuals with spinal cord injuries
Hospitalized patients
Individuals in long-term care facilities
Pressure ulcers formation a result of:
Inverse pressure–time relationship
Individual hemodynamic factors
Body location
Etiology of Pressure Ulcers
Areas overlying bony prominences are at greatest risk for ulcerations
Muscle more sensitive to pressure than skin
Pressure ulcers may not develop for days after the pressure was applied
Reactive hyperemia
localized area of blanchable erythema
Risk Factors Contributing
to Pressure Ulcers
Shear Excessive moisture Impaired mobility Malnutrition Impaired sensation Advanced age History of pressure ulcer
Shear:
force parallel to soft tissue
Appearance of shear:
teardrop appearance
undermining common
Friction:
two surfaces moving across one another
How does moisture predispose skin to pressure ulcers?
Causing maceration
Increasing shear
Increasing friction forces
Maceration by be caused by:
Wound drainage
Perspiration
Incontinence
Anhydrous skin also at risk
What is the second most common risk factor in PU?
malnutrition
Malnutrition
Low serum albumin levels and/or hydration
Correlated with ulcer severity
Patient may be underweight, normal weight,
or obese
Reduced Mobility
Weakness, sedation, depression
Who is reduced mobility frequently studied in?
Hospitalization
Fracture
Spinal cord injury
Infants/neonates
Impaired Sensation
Unable to detect pain of ischemic tissue damage caused by pressure
Examples of impaired sensation:
Spinal cord injury Spina bifida Stroke Diabetes mellitus Full-thickness burns Peripheral neuropathy
Advanced Age
More than half of patients with pressure ulcers are over 70 years old
Age-related skin changes
Increased rate of comorbidities
Previous Pressure Ulcer
Scar tissue only attains up to 80% strength of the original tissue
Scar tissue alters tolerance to pressure and externally applied loads
Additional Risk Factors for PU:
Ischemia-reperfusion injuries Polypharmacy Low diastolic pressure Psychosocial factors Smoking Increased skin temperature Diabetes-related microvascular changes Alzheimer’s disease, Parkinson’s disease, RA
Pressure Ulcer Risk Assessment Tools
Screening devices
Should have high specificity and sensitivity, be easy to use, and be linked to interventions
The most widely used and researched tools for PU:
Braden Scale for Predicting Pressure Sore Risk
Norton Risk Assessment Scale
Gosnell Pressure Sore Risk Assessment
Braden Scale
High interrater reliability
Braden Q scale for pediatric patients
Scores range from 6 to 23, with lower scores indicating greater impairment and higher risk
At risk score in Braden Scale:
less than 18
Six indicators in Braden Scale:
Sensory perception Moisture Activity Mobility Nutrition Friction or shear
Norton Risk Assessment Scale
May overpredict incidence of pressure ulcers
Each scale is rated 1 to 4, with lower scores indicating greater risk of pressure ulcer development
At risk score in Norton Risk Assessment:
less than or equal to 16
Gosnell Pressure Sore Risk Assessment
Each scale is rated 1 to 5, with 1 being the least impaired
16 is the critical cut-off score
Least researched tool
Five subscales of Gosnell Pressure Sore Risk Assessment:
mental status, continence, mobility, activity, and nutrition
Interdisciplinary interventions for pressure ulcer prevention
Prevention
- education
- positioning
- mobility
- nutrition
- management of incontinence
NO ULCERS
Nutrition and fluid status Observation of skin Up and walking or assist with position change Lift, don't drag Clean skin and continence care Elevate heels Risk assessment Support surfaces
SKIN
Surface selection
Keep turning
Incontinence management
Nutrition
Stage I PU:
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.
Area may be painful, warmer, cooler, firmer, softer than surrounding tissue
Tissues involved in stage I:
May be superficial
May be first sign of deeper tissue involvement
Stage II PU:
Superficial ulcer
Shallow crater without slough or bruising
May be ruptured or intact blister
Tissues Involved in Stage II:
Partial thickness (epidermis, dermis, or both)
Stage III PU:
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.
Tissues involved in Stage III PU:
Full thickness (epidermis, dermis, subcutaneous tissue) Bone/tendon not visible
Stage IV PU:
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.
Deep ulcer with extensive necrosis
Tissues involved in Stage IV PU:
Full thickness
Underlying deep tissue exposed
Unstageable PU:
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.
Tissues involved in unstageable PU:
Full thickness
Will be category III or IV
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.
Intervention Goals for PU:
Off loading
Fill dead space
Control exudate
Decrease microbial load
Goals for Stage 1 and 2 PU:
film dressings to prevent sheer allow oxygen to get to area, but block bacteria/contaminants, autolytic debridemen
Limitations of Classification System:
Category/stage I pressure ulcer is not an
ulcer by definition
Clinicians may erroneously “reverse stage” a pressure ulcer
Significant revision of prior system – may take time to adapt to and use correctly
Benefits of Classification System:
Promotes uniform understanding of the depth of tissues involved
Excellent reliability
Clinicians must stage pressure ulcers for Medicare reimbursement
Determines type of support surface to be used
Can be used for research studies
“5PT” Method
Pain Position Presentation Periwound Pulses Temperature
Pain:
McGill Pain Questionnaire, Visual Analog Scale, Faces Pain Scale
Category I pressure ulcers may be tender instead of painful
Patients with neurological deficits may not perceive pain
Patients who are unable to communicate may demonstrate pain by grimacing, withdrawal, or moaning
Position:
Majority on lower half of body over boney prominence
Areas of outside pressure:
casts, tubing, shoes
Where are 95% of PU located:
sacrum, greater trochanter, ischial tuberosity, posterior calcaneous, lateral malleolus
Pressure Ulcers: Common Sites
Ischial tuberosities Greater trochanters Sacrum/ Coccyx Lateral malleoli Heels Olecranons Medial femoral condyles Occiput
The most common sites for PU while seated:
ischial tuberosity, greater trochanter if in a sling-like seat, and sacrum/coccyx if in a posterior pelvic tilt
Presentation
International NPUAP/EPUAP Ulcer Classification System provides detailed descriptions
Patients with full-thickness pressure ulcers more likely to have multiple ulcers
Periwound and Structural Changes
Nonblanchable erythema
Mottled
Ring of inflammation around ulcer
Dermatitis
Pulses
Usually not applicable due to proximal ulcer location
Usually normal unless concomitant PVD
Temperature
Increased in areas of reactive hyperemia
Decreased in areas of ischemia
PU Assessment Instruments
Measure changes in wound status
Evaluate the effectiveness of plan of care
Document wound severity
Promote quantification of wound parameters
Standardize wound assessment
Facilitate reimbursement
Sessing Scale
7-point observational scale describing wound and periwound characteristics
Scores range from 0 to 6
Used in clinic and research settings
Sessing scale stage 0:
normal skin, but at risk
Sessing scale stage 1
skin completely closed
may lack pigmentation or may be reddened
Sessing scale stage 2
wound edges and center are filled in
Surrounding tissues are intact and not reddened
Sessing scale state 3
wound bed filling with pink granulation tissue
slough present
free of necrotic tissue
minimum drainage and odor
Sessing scale stage 4
moderate to minimal granulating tissue
slough and minimal necrotic tissue
moderate drainage and odor
Sessing scale stage 5
presence of heavy drainage and odor; eschar and slough
surrounding skin reddened or discolored
Sessing scale stage 6:
breaks in skin around primary ulcer
purulent drainage, foul odor, necrotic tissue or/and eschar
may have septic symptoms
Bates-Jensen Wound Assessment Tool (BWAT)
Formerly the Pressure Sore Status Tool (PSST)
13 items
Rated 1 to 5 scale
Describe wound and periwound characteristics
Total scores range from 13 to 65
Higher scores indicate increased severity
Reliable and valid
Used in clinic and research settings
Pressure Ulcer Scale for Healing (PUSH)
3 subscales
Wound surface area, exudate amount, appearance
Total score ranges from 8 to 34
Higher scores indicate increased severity
Limited research
Prognosis for Pressure Ulcer Healing
Pressure ulcers heal very slowly
Expected ulcer healing time with appropriate interventions
Category I ulcers heal:
within 1-3 weeks
Category II ulcers heal:
within days to weeks
Category III and IV ulcers heal:
take an average of 8–13 weeks
Precautions For PT:
Pressure ulcer depth can be deceptive
Probe regularly
Ensure wound care goals and interventions are consistent with patient’s overall plan of care
Request for Further Medical Testing
Culture Wounds
Assess for osteomyelitis
Early surgical consult for patients with deep pressure ulcers
Culture wounds
That fail to progress in timely manner
That show signs/symptoms of infection
Assess for osteomyelitis
Wounds with exposed bone
Deep wounds with purulent or malodorous drainage
Keys to Local Wound Care
protect surrounding tissue address wound bed minimize pressure and shear support surface technology educate patient and caregivers
Protect the Surrounding Tissue
Moisturize dry skin
Use moisture barriers and skin sealants to protect
Address Wound Bed
Choose dressings to provide a moist wound bed
Debride necrotic tissue if appropriate
Control infection
Charcoal dressings control odor
Do not debride:
stable, hard, dry, eschar-
covered wounds in ischemic limbs
What is breakdown pressure?
32 mmHg
What should pressure be reduced to?
23mmHg-32mmHg
presure relieving: under 23mmHg
Minimize Pressure and Shear:
Tissue interface pressures
Pressure-reducing devices
Pressure-relieving devices
Static and dynamic support surfaces
Support Surface Technology
Must consider all surfaces patient will be on
Bed, commode, chair, car seat, etc.
Consider patient’s needs
Pressure redistribution, shear reduction, continence, temperature and moisture control
Consider patient mobility
Ability to reposition, transfer
Consider patient status
Deformities, body weight, tissue status, risk for recurrence
Category 1 support surface:
Mattresses and mattress overlays
Category 2 support surface:
Specialty mattresses
Pressure-reducing foam, alternative air, low air loss
Category 3 support surface:
Air-fluidized beds
Educate Patient and Caregivers
Wound etiology
Intervention strategies
Risk factor modification
Guidelines for pressure ulcers
Therapeutic Exercise
Flexibility exercise to minimize contractures
Strengthening exercise
Assist with mobility, transfers, and weight shifts
Pelvic floor and abdominal muscle strengthening to assist management of incontinence
Aerobic Exercise
Improves cardiovascular endurance for improving mobility and activity
Functional Training
Gait training
Transfers and bed mobility
Emphasize minimizing friction and shear
Protect intact skin and any existing pressure ulcers
Electrotherapeutic Modalities
Pulsatile lavage with suction If no evidence of healing with standard care: Electrical stimulation Ultraviolet Ultrasound Negative pressure wound therapy
Medical Testing
Wound culture
Bone scan
Malnutrition
Medical Interventions
Manage risk factors Malnutrition Anemia Diabetes Incontinence Pharmacological interventions Pain Infection
Surgical Interventions
Debridement
Musculocutaneous flaps
Highly vascular
Provide tissue bulk to fill defect and provide padding
Drain in place for 1 week
Avoid pressure and shear post-operatively
Monitor temperature/color/capillary refill
