“Nurse, I See RED…..”

Maintaining skin integrity, it

can be done!

Developed by: Carol Balcavage, RN, WOCN, 2004

The Audience

This education program was designed for the caregiver

who spends the most time at the patient’s bedside . . .

“The Nursing Assistant”

Objectives

A. The learner will identify the cause of pressure ulcers.

B. The learner will identify factors that contribute to the development of a pressure ulcer.

C. The learner will identify the role of the Nursing Assistant in prevention of pressure ulcers.

The Patient’s Skin

• Largest organ in the body, equals

12-15% of body weight and receives one third of the body’s circulating blood volume

• Functions– Protection– Thermoregulation– Sensation– Metabolism

Maintaining Skin Integrity

• Is everyone’s responsibility

• Patient’s first line of defense from infection

• Many forms of skin integrity issues– Bruises, skin tears, cracks, shearing,

erosions, scratches, blisters, pressure ulcers– Hospital acquired pressure ulcers are of great

concern

What is a Pressure Ulcer?

• Any injury caused by unrelieved pressure that damages the skin and underlying tissue (fat, muscle, bone). Also called decubitus ulcers, pressure sores or bed sores

• Severity ranges from reddening of skin to deep craters extending to muscle and bone

Why are Pressure Ulcers a Problem?

• Pressure ulcers can produce poor outcomes for patients including loss of a limb or even death

• Pressure ulcers are costly– Increased length of stay– Added hospital costs– Additional recovery time– Pain– Potential for litigation

Risk Factors

• Moist skin– Perspiration– Incontinence– Wound drainage

• Limited activity and mobility• Inability to change position independently

in bed or in chair• Assistance required to get out of bed• Assistance required to walk

Risk Factors

Loss of sensory perception– Paralysis (loss of voluntary motion and/or

sensation)– Neuropathy (“pins & needles” sensation in

affected limb, decrease in sensation)– Decrease in mental awareness

Risk Factors

• Altered blood flow– Decreased flow of blood to extremities

• Vascular patients• Diabetic patients

– Edema– Hypotensive episode (low BP)

Risk Factors

• Friction and Shearing– Friction – abrasion of the top layer of skin– Shearing – the skin separating from

underlying tissues

Risk Factors

• Poor nutrition

• Poor hydration

What Does a Pressure Ulcer Look Like?

What Does a Pressure Ulcer Look Like?

• There are four stages of pressure ulcer plus unstageable– Stage I: the ulcer appears as a

defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues

Special Consideration for Pigmented Skin

• Check skin compared to an adjacent or opposite area on the body – Skin temperature (warmth or coolness) – Tissue consistency (firm or boggy feel) – Sensation (pain or itching)

What Does a Pressure Ulcer Look Like?

• Stage II: ulcer is superficial and presents clinically as an abrasion, blister or shallow crater

• Stage III: full thickness of skin is lost, exposing the subcutaneous tissue

• Stage IV: full thickness of skin andsubcutaneous tissue is lost,exposing muscle or bone

What Does a Pressure Ulcer Look Like?

Unstageable: ulcer is covered with

dead tissue which may be black,

brown or yellow

What Can You Do to Prevent Pressure Ulcers?

• Each person plays an important role• Communication and timely reporting is critical• Other resources are also available such as the

patient’s family and friends, the chaplain, volunteers and the WOC/ET nurse

• However, it is the “Nursing Assistant” who spends the most time with the patient and who can make the biggest difference in preventing pressure ulcers

Prevention: Decrease Excessive Moisture

• Good skin care– Bathe patient daily paying particular

attention to skin folds and perineal tissues

– Use skin cleansers with a low pH and skin protectant on all incontinent patients and patients who use a bedpan

– Place absorbent material between the skin folds of obese patients

Prevention: Decrease Moisture

• Good Skin Care– Limit use of diapers to patients who are out of

bed or who have large amounts of urine or diarrhea at one time

– Check incontinent patients frequently– Discuss a toileting schedule with the RN– Avoid plastic barriers and sheepskin– Communicate any signs of redness to RN

Prevention Sensory Perception

– Inspect patient’s skin for areas of redness with every position change

– Avoid massaging or rubbing bony prominences (Use a gentle touch when cleansing skin and applying ointments)

– Turn and reposition every two hours (minimum)

– Elevate heels off of bed surface– Check position of foot in the heel protection

device and reposition as necessary

Prevention Sensory Perception

• Remove compression stockings for ½ hour twice each day and check heels. If patient is at risk for heel breakdown, check more frequently

• Perform active and passive range of motion (ROM) of all involved extremities

Prevention: Activity/Mobility

• Encourage patient to change position frequently or turn and reposition patient every two hours

• If patient is not moving because of poor pain control, discuss with the RN

• Promote ambulation at regular intervals (consider PT consult if patient has difficulty with mobility)

Prevention: Activity/Mobility

• Out of bed to chair no longer than two hours at one sitting

• Reposition in chair after one hour. If patient is able to do so, remind to shift position every 15 minutesHint: Suggest that position be shifted each time there is a commercial on TV

• Use chair cushion if patient is at risk

Prevention: Altered Circulation

• Report the following unexpected changes to the RN:– Change in vital signs and color– Change in temperature of skin surfaces– Decrease in urine output– Swelling in any body tissues

Prevention: Altered Circulation

• Keep in mind that patients with altered circulation are susceptible to skin damage from heat and cold from items such as:– Heating pads– Hot packs– Cold packs

Prevention: Friction/Shearing

• Use moisturizers on dry skin surfaces where applicable and use a bathing system that incorporates emollients like Vitamin E and Aloe

• Assess need for assistive devices (heel protectors, extra pillows)

• Use turning and transfer aids (i.e., lift sheets, trapeze)

Prevention: Friction/Shearing

• Prevent shearing by maintaining bed at 30 degrees or less and gatch knees

when possible• Have patient use a trapeze when indicated• When using lift sheet to move patient to top of

bed• Avoid dragging any part of patient’s body

– Put socks on patient’s feet– Ask patient to bend knees and to push against bed surface

Prevention: Friction/Shearing

• Powder bedpan edges before placing patient on bedpan

• Pad patient’s buttocks and or transfer board when getting patient in and out of bed with transfer board

• Use elbow protectors when indicated

• Maintain proper positioning in chair

Prevention: Nutrition & Hydration

• Monitor weight on admission and weekly• Monitor fluid status, I & O as appropriate• Monitor/encourage nutritional intake

recommendations (target: meal completion over 75%)

• Accurately record calorie counts• Give patient nutritional supplements as

ordered

Prevention: Nutrition & Hydration

• Provide patient with hand wipes before and after meals. Also provide opportunity to brush teeth

• Whenever possible, get patient out of bed for meals

PREVENTION is key!

Review

Now let’s test your knowledge

Select the best answer

A. A pressure ulcer is a surgical wound.

B. A patient with poor circulation is not at risk for developing a pressure ulcer.

C. Pressure ulcers are caused by unrelieved pressure.

D. No one develops a pressure ulcer at my hospital.

Select the best answer

A. A patient with reduced sensation in his feet is at risk for developing a heel ulcer.

B. Good nutrition leads to bedsores.

C. Moist skin due to perspiration is not a risk factor.

D. A patient who is paralyzed is not at risk for developing a pressure sore.

Select the best answer

A. I really don’t worry about pressure ulcers, that’s the nurse’s job.

B. All patient’s have red heels.

C. I report any reddened area to the RN.

D. I check my incontinent patients every four hours.

Select the best answer

A. I do not need to report every red mark that my patient gets on his skin to the RN.

B. The RN is the only one who can prevent pressure ulcers.

C. A little pressure sore on my patient’s foot is not very important.

D. It takes team work to prevent pressure ulcers and I’m a key player on that team.

Answer Key

C. Pressure ulcers are caused by unrelieved pressure.

A. A patient with reduced sensation in his feet is at risk for developing a heel ulcer.

C. I report any reddened area to the RN.

D. It takes team work to prevent pressure ulcers and I’m a key player on that team.

References

Ayello EA, Baranski S, Lyder CH, Cuddingan J. Pressure ulcers. In:Baranski S and Ayello EA. Wound Care Essentials: Practice Principles. Springhouse, PA: Lippincott Williams & Wilkins: 2004. p 240-70.

Calianno C, Assessing and preventing Pressure Ulcers. Adv Skin Wound Care; 2000; 13(5):244-246.

Hess CT. Skin Care Basics..Adv Skin Wound Care 2000; 13(3):127-129.

Panel on the Prediction and Prevention of Pressure Ulcers in Adults. Pressure Ulcers in Adults:Prediction and Prevention. Cliical PracticeGuideline,No.3 AHCPR Publication No. 92-0047. Rockville,MD:Agency for Health Care Policy and Research; May 1992.

Ratcliff CR,WOCN’s Evidence-Based Pressure Ulcer Guideline. Adv Skin Wound Care 2005; 18(4):204-207.

Zulkowski,KM, Tellez R, van Rijswijk L. Documentation with MDS Section M: Skin Condition. Adv Skin Wound Care 2001; 14(2):81-89.

Lehigh Valley HospitalAllentown, PA

Developed by:

Carol Balcavage, RN, WOCN, 2005