TOPIC: PRESSURE ULCER

OUTLINE• INTRODUCTION• ANATOMY OF THE AFFECTED ORGAN • IMPORTANCE OF THE TOPIC• DEFINITION OF PRESSURE ULCER• AREAS COMMONLY AFFECTED• VULNERABLE GROUPS• RISK FACTORS• PATHOPHYSIOLOGY OF PRESSURE ULCER• STAGES OF PRESSURE ULCER• RISK ASSESEMENT TOOL• PREVENTION OF PRESSURE ULCER• EVIDENCED BASED PRACTICE• WHEN ULCER IS FORMED• PRESSURE ULCER SCALE HEALING• CONCLUSION

INTRODUCTION• Pressure ulcer is a significant problem among

critically ill patients and older people who are nursed in long term facilities, it is a problem both at home and hospital settings and the % of clients who develop pressure ulcer are increasing on a daily basis.

• Pressure ulcer causes physical, social, and psychological suffering, delayed rehabilitation and economic hardship, its also one of the causes of litigation in developed countries.

• Globally, maintaining skin integrity and preventing pressure ulcer have traditionally been the responsibility of nurses caring for hospitalized patients.

ANATOMY OF THE HUMAN SKIN

ANATOMY OF THE HUMAN SKIN

ANATOMY OF THE HUMAN SKIN

IMPORTANCE OF THIS TOPIC• Proportion of emerging admission of critically ill patients

continues to rise in our hospitals.• Nurses work under high pressured environment thereby

exposing the at risk patients to tissue breakdown creating a problem which is not just a ‘‘problem for nursing but a health system problem which undermines health system effectiveness’’

• National institute for clinical excellence (NICE) now view pressure ulcer as an indicator of the quality of care provided & is consequently of high demand on the political &health agenda

• Hulsenboom, Bours & Halfans (2006)asserted that today, the presence of pressure ulcers in hospitalized patients has been identified as a quality indicator in health care thereby posing a great challenge for nurses when caring for patients who are at risk of developing pressure ulcer

WHAT IS PRESSURE ULCER• Pressure ulcer is an area of localized damage to the

skin and underlying tissue caused by pressure, sheer friction and/ or a combination of these condition (Clark, Bours, Defloor, 2004).

• It is a lesion caused by unrelieved pressure (a compressing downward force on a body area)

• According to Tweed and Weatherall (2005) pressure ulcers traditionally are thought to affect only those who are bedridden and older adults, however they can affect patients of all ages and in different care environment.

• Pressure ulcers can develop on any part of the body where sustained pressure and compressive forces are maintained for a sufficient period of time

AREAS COMMONLY AFFECTED BY PRESSURE ULCER • Areas where the bones are lying superficial to the skin

such as• Temporal region of the skull• Back of the head• Shoulder blades• Elbows• Vertebral column• Sacrum• Ischial tuberosities• Femoral trochanters• Lateral and medial maleolus• Heels• Toes

Vulnerable groups• Patient with spinal cord injuries• Unconsciousness• Diabetes• Patients with orthopedic surgery• Intensive care unit patients• Elderly patients especially those suffering from

dementia• Malnutrition• History of previous ulceration• Incontinence• Paralyzed etc

RISK FACTORS• Friction and shearing• Immobility• Inadequate nutrition• Fecal and urinary incontinence• Decreased mental status: unconscious heavily sedated dementia

• Diminished sensation paralysis, stroke, neurologic disease

• Advanced age decreased strength &elasticity of the skin,loss of lean body mass&,thining

• Excessive body heat• Chronic medical conditions• Incorrect positioning• Incorrect application of pressure relieving devices• Bread crumbs and creases in beds• Poor lifting and transferring technique

PATHOPHYSIOLOGY OF PRESSURE ULCER• When pressure applied to the skin tissue over time

is greater than 32mmHg (normal capillary closure pressure), unrelieved pressure result in tissue ischemia & anoxia. The cells are deprived of nutrients & waste product accumulates & the tissues consequently dies. The skin first appear pale, the skin immediately becomes reddened (reactive hyperemia)which disappear shortly if there is no tissue damage, when redness persist, tissue damage has occurred, there is progressive destruction of underlying tissues & slough is formed, when the slough separates it leaves an ulcer. Ulcer is usually painful, heals slowly & subject to secondary infection, if large, there is continuous loss of blood cells

STAGES OF PRESSURE ULCERStage 1: Non blanchable erythema. Which is a sign of potential necrosisStage 2:Partial skin loss (abrasion)involving the epidermisStage 3:Full thickness skin loss involving the subcutaneous tissueStage 4: Full thickness tissue loss with damage of muscle, bone or supporting structures e. g tendon or joint capsule

RISK ASSESMENT TOOLThe risk assessment tool provide the nurse the

systematic means of identifying clients at risk of pressure ulcer development; examples are:

Braden scale which consist 6 subscales Sensory perception mobility

moisture nutritionactivity friction & shearing

Total score=23points, adult with 18 points or less is at riskNorton pressure area risk assessment form scale General physical condition incontinence

mental state mobilityactivity category of medications

PREVENTION OF PRESSURE ULCER EVIDENCE BASED APPROACHES• Early identification of individual who are susceptible or at risk,

using the risk assessment tool within 6hours of admission, reassessment should be done weekly.

• Skin inspection should occur regularly.• During bath, avoid force & friction on the skin, use mild soap,

minimize irritation. • Minimize skin dryness by avoiding cold& low humidity, apply

moisturizes after bath• Keep the skin clean& dry always, free from irritation of urine

feces, sweat or incomplete dryness after bath., use barrier creams when necessary.

• Provide the client with smooth, firm, creases & wrinkle free bed on which to sit or lie.

• Position ,transfer & turn clients correctly. Avoid dragging in bed, use a lifting device e. g. a trapeze.

• Risk level, level of tissue tolerance, medical or physical conditions, comfort level

PREVENTION OF PRESSURE ULCER CONTD• Repositioning, even if slight, at least every 2hrs for bed bound

persons, chair-bound persons every hour. A written repositioning schedule should be used. Six (6)positions can be used. Prone, supine, right &left lateral, right & left sim’s positions.

• Teach chair-bound clients who are able to shift weight every 15minutes

• Use pressure reducing devices e. g. pillows, air rings, heel protector, foam mattress, waterbed.

• Give adequate nourishing diet, give nutritional supplements to nutritionally compromised clients, monitor weight & nutritional status.

• Institute a rehabilitation program to maintain or improve mobility/activity status.

• Encourage active & passive exercises while in bed• Avoid massage of bony prominences.• Monitor and document interventions and outcomes.

EVIDENCE BASE PRACTICE• Massage over pressure areas should be avoided,

Traditionally, nurses massage to stimulate blood circulation with the intention of preventing pressure ulcer. However, scientific evidence does not support this belief, vigorous massage may lead to deep tissue trauma.

• Baby powder & cornstarch are never used as friction or moisture prevention, powders create harmful abrasive grit damaging to tissues and are considered a respiratory hazard.

• Avoid the use of petroleum based creams & ointment as barrier creams as they cause poor skin protection. Dimethicone based creams, or alcohol free barrier films in liquid, spray or moist wipes are better

WHEN AN ULCER IS FORMED• Minimize direct pressure on the ulcer, document

position changes in clients chart.• Correct the underlying causative factors • Provide range of motion exercise& mobility out of

bed as the clients position permits• Clean the ulcer with every dressing change.• Clean and dress ulcer adequately using surgical

asepsis, never use alcohol or hydrogen peroxide as they are cytotoxic to tissue beds

• Perform wound debridement where neccessary• Collect wound swab sample for C & S if ulcer is

infected• Teach client to move even if slightly to relieve

pressure

PRESSURE ULCER SCALE FOR HEALING (PUSH TOOL)

LENGTH XWIDTHIn cm2

0

0

1

<0.3

2

0.3-0.6

3

0.7-1.0

4

1.1-2.0

5

2.1-3.0

Sub score

6

3.1-4.0

7

4.1-8.0

8

8.1-12.1

9

12.1-24.0

10

>24.0

Sub score

EXUDATE

AMOUNT

0none

1light

2moderate

3heavy

Sub score

TISSUETYPE

0closed

1epithelial tissue

2granulation tissue

3slough

4necrotic issue

Sub score

NURSING MANAGEMENT• ASSESSMENT• NURSING DIAGNOSIS Risk for impaired skin integrity Impaired skin integrity Impaired tissue perfusion• PLANNING• NURSING INTERVENTION Improve mobility Use pressure relieving devices Position the patient• EVALUATION: Expected outcome may be• Increasing mobility• Maintaining intact skin• Limiting pressure on bony prominences• Experiencing healing of pressure ulcer• Demonstrating improved tissue perfusion

CONCLUSION• Pressure ulcer disease represent a major health

problem both in this country & internationally, The nurse needs knowledge and skills relating to the cognitive process of problem solving in order to successfully prevent the occurrence of pressure ulcer

• As much as nurses consider the maintenance of skin integrity as their primary domain; No health care personnel works in isolation, hence a multidimensional collaboration is significant in the prevention of pressure ulcer, treatment and regimens should be implemented in collaboration with other members of the team, the multifactorial nature of the problem require the physiotherapists, dietician, pharmacist& doctors support.

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