Pressure Ulcers

Pressure Ulcer Definitions

“Any lesion caused by unrelieved
pressure, friction, and/or shear
that results in damage to
underlying tissue.”
Bergstrom et al, 1994

“A localized area of tissue

necrosis that develops when soft
tissue is compressed between a
bony prominence and an external
surface for a prolonged period of
time.”
Krasner, 1997
 Pressure Ulcer
Facts

• Neurologically impaired:
- incidence of 5-8% annually
- lifetime risk estimated to be 25-85%

• Nearly 60,000 people die each year as a result of

a pressure ulcer (U.S.)
• Direct cause of death in 7-8% of all patients
with paraplegia
Revis et al, 2001
 Pressure Ulcer
Facts
• 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
Recurrent Trauma- Stage 1
& 11 pressure ulcers –
compromised by friction &
shear
 Etiologic Factors

Pressure

Shear

Treat the cause Friction

Moisture

Poor Nutrition
 Pressure
Capillary Closing Pressure

Occurs when pressure applied to

the skin and underlying tissues
exceeds pressures within the
capillaries

No blood, no oxygen,
tissue dies
 Pressure
Capillary Closing
Pressure
Maintenance of interface pressure
below capillary closing pressures
– gold standard for pressure
relief/reduction

32mmHg represents average

capillary pressure on a healthy
males finger tips

Range of capillary pressure less then 20 mm Hg

to more than 40 mm Hg
 Pressure
Highest between the bone and soft
tissue

Tissue injury starts at the bone/tissue

interface
and extends outward

Accounts for undermining

 Pressure
Inverse relationship between the amount of
time & intensity of pressure

Pressure = Force/area

low pressure High Pressure

- long duration -short
duration
 Other Predisposing Factors to
Pressure Ulcers

Intrinsic - decreased mobility (fractures,

surgery) decreased ability to weight shift
or reposition independently

Poor Nutrition

Altered blood pressure

Circulatory impairment
Other Predisposing Factors to Pressure
Ulcers

Decreased sensation spinal injury,

neuropathy
Increased age – 50% of pressure ulcers
develop in those 75+
Coexisting health conditions (Diabetes)
Lowered mental awareness (dementia,
depression)
Body build
 Other Predisposing Factors to
Pressure Ulcers
Extrinsic – failure to recognize risk
inadequate treatment protocols
trauma from patient handling techniques
inadequate hydration
medications
emotional stress
smoking
 Pressure Ulcer
Assessment/Diagnosis
Complete patient history

Nutritional assessment

Investigations

Risk assessment

Wound assessment
 Complete Patient History
Determine general health & risk
factors that may predispose to
wounding &/or adversely affect
healing

Cause,duration,history & treatment of

previous & current pressure ulcers
talk to them – they will tell
you everything- patience
 Complete Patient
History
Co-existing medical conditions optimal
management of: cardiac, renal,
gastrointestinal, collagen-vascular,
neuromuscular, haematological
disorders, including anaemia &
diabetes

Medications(systemic corticosteroids,
chemotherapeutic)
 Complete Patient History
Recent acute illness – lethargy, immobility

Client's ability and motivation to comprehend and

adhere to treatment program
mental status
Can They Read learning ability
depression,dementia,delirium
Available resources
Pain
 Nutritional Status

Consult Dietician if indicated

Albumin or Pre- Albumin

(in serial measurements)

Measure height, monitor weight at regular

scheduled intervals
 Investigations

Investigations should be based on;

Patient assessment

Risk factors

Severity of pressure ulcers

 Risk Assessment

Complete risk assessment using either the Braden

Scale, Norton Pressure Ulcer Risk Assessment
Scale, or Pressure Sore Status Tool (PSST)
(Bates-Jensen 1990)

Should be done on admission and at scheduled

intervals or when deterioration in health status

Score on tools may be less important then

identification of major risk factors

Key is to develop a care plan based on identified

risks
 Investigations
May include:

blood pressure

CBC, ESR, Urinalysis

HgbA1c Glucose ( adequacy of glycemic

control)

Wound culture – only if infected

X-ray &ESR (if osteomylitis suspected)

Bone scan ( if x-ray and
ESR inconclusive)
 Predicting Pressure Ulcer Risk

Pressure ulcers (PUs) occur frequently in

hospitalized, community-dwelling and
nursing home older adults, and are
serious problems that can lead to sepsis
or death.

Prevalence of PUs ranges from 10-17% in

acute care,0-29% in home care, and 2.3-
28%in

Institutional long-term care (LTC);

incidence ranges from 0.4-38% in acute
care, 0-17% in home care,
Elizabeth
FAPWCA,
A. Ayello,and
FAAN 2.2-23.9%
PhD, APRN, BC, CWOCN,

in institutional LTCExcelsior College School of Nursing

 The Braden Scale
The Braden Scale for Predicting Pressure
Sore Risk is among the most widely used
tools for predicting the development of
PUs.

-Assessing risk in six areas (sensory

perception, skin moisture, activity,
mobility, nutrition and friction/shear),

- assigns an item score ranging from one

(highly impaired) to three/four (no
impairment).

- Summing risk items yields a total overall

Elizabeth A. Ayello, PhD, APRN, BC, CWOCN,
FAPWCA, FAAN
Excelsior College School of Nursing
Permission to use received from Barbara Braden and Nancy Bergstrom as required
 Using Braden Scale

Score resident in all six categories according to

provided descriptions

A score of < or = 3 in any category identifies a risk

Total score of:

15 to 18 = low risk
13 or 14 = moderate risk
10 to 12 = high risk
< 9 = very high risk
Elizabeth A. Ayello, PhD, APRN, BC, CWOCN,
FAPWCA, FAAN
Excelsior College School of Nursing
 Other Risk Assessment Tools

Norton Pressure Ulcer Risk Assessment

Tool

Pressure Sore Status Tool (PSST)

Bates – Jensen 1990

National Pressure Ulcer Advisory Panel

(NPUAP)

You need to be aware of what the tool

chosen in you practice is and how to use it
 Pressure Ulcer Wound Assessment
Stage I- Non-blanchable erythema of
intact skin after 30 min. of pressure relief
-pigmented skin may appear blue/purple/black with
warmth to the area

Staging according to National

(NPUAP) injury severity
Guidelines, 1989

Stage II- partial thickness skin loss involving

epidermis/dermis
- superficial and presents as an abrasion, blister, or
shallow crater
 Pressure Ulcer Wound
Assessment

Stage III-full thickness involving

damage or necrosis of
subcutaneous tissue, may extend
down but not through the fascia
- presents clinically as deep
crater with or without
undermining of adjacent tissue
 Pressure Ulcer Wound Assessment

Stage IV- full thickness skin loss with extensive

destruction, tissue necrosis, or damage to muscle,
bone, or supporting structures (tendon, joint
capsule)

Stage X – ulcer covered by necrotic tissue or eschar.

Unable to accurately stage ulcer until devitalized
tissue is removed
 NPUAP
Pressure Ulcer Staging

Only appropriate for defining maximum

anatomic depth of tissue damage

Reverse staging is not appropriate to

measure pressure ulcer healing
A stage IV healing wound would still be a
Stage IV healing partial thickness wound-
not a Stage III
 Treat the Cause
Pressure Reduction
Turning & Repositioning
Minimize Friction & Shear
Manage Moisture
Maximize Nutrition
Enhance Mobility & Activity
Preventative Skin Care
 Pressure Reduction
Protect bony prominences with foam
wedges, pillows, heel protectors, at sites of
previous ulcers

Watch the ears from pillows, behind ears

and cheek bones from tubing
Pressure Reduction

Pressure relief mattresses,

pressure reduction mattresses ( static,gel,air,
alternating), seat cushions
Avoid the use of “donut” type devices
Do not massage red areas
protect with appropriate
dressings and turning,
positioning
 Pressure Reduction
Mattresses and seating devices depend on
location and severity of the ulcer, the number
of available turning surfaces, pain and mobility

Consult OT & PT for suggestions

Consult advanced wound care clinician as

indicated (moderate to high risk, existing or
recently healed pressure ulcers)
 Pressure Reduction/Relief

Pressure Reduction -
products that reduce the interface
pressure, but not necessarily below the
level required to close capillaries. Surface
should become displaced by bony
prominences

Pressure Relief -
Products reduce interface pressure
below capillary closing pressure. Surfaces
will become displaced by bony
prominences
 Manage Tissue Load
Definition: distribution of pressure, friction,
and shear on the tissue

Goal: to create an environment that will

enhance soft tissue viability and promote
healing

Requirements:proper positioning
techniques and support surfaces whether
in bed or sitting
Pressure Management Mattresses
Foam mattress or overlay (Geomat,
Australian sheep Skin)

Air Mattress
Static mattress- fixed amount of air in
tubes – no movement
Dynamic Powered – alternating pressure,
low air loss
Dynamic non-powered – air moved by
response to load
Gel – wide range of viscosities
 Mattress Types

Alternating Pressure
Foam
Static Air

Alternating – air loss Low air loss

replacement mattress
 Turning & Positioning
Evaluate bed mobility & develop a turning
schedule based on:
Risk
• Mild
• Moderate
• High

Use written repositioning

schedule to ensure
Turning
consistency & continuity
schedule
 Mild Risk

If patient moves easily

& frequently in bed

Evaluate bed mobility & ensure adequate

turning every 3-4 hours
 Moderate Risk
If patient is not able to shift
position independently:
• Reposition every two hours
• Use foam wedge or pillow
– Start at 30º angle then gradually decrease
angle of wedge to 20º, 10º, then turn patient.
(small body movements performed as often
as q 15 minutes)
– NOTE: Avoid 90º - (directly on the
trochanter)- side-lying position
 High Risk
If patient is bed fast,
completely dependent,
heavily sedated, &/or
has an existing pressure ulcer(s)
• Turn every 2 hours.
• Supplement with small shifts using foam
wedge or pillow.
• Therapeutic surface
• Use pillows & cushions to separate bony
prominences from direct contact with one
another!
Chair Positioning For people at risk for
pressure ulcers:
• Avoid uninterrupted sitting
(chair/wheelchair)
• Reposition every hour (May
alternate sitting with lying)
• Shift position every 15
minutes (teach patent) Do not forget to protect
elbows, heels,calves,
and shoulders
• Consider postural alignment, weight
distribution, balance, & stability
• Ensure cushion positioned properly
• Consult OT or PT for seating
assessment
• Be aware of air seating, special
cushions or chairs
Pressure relief for heels
 Shear/Friction
Shearing forces are produced when adjacent
surfaces slide across one another

Can occur when skin and superficial fascia remain

fixed, while the deep fascia slide down with
gravitational force

Causes stretching, pulling, &

changes to the angle of the vessels
>> ischemia

Head of bed
should not be elevated over
30 degrees
 Shear/Friction
Friction:

Created by movement of the patient usually

repeatedly, over surfaces such as bed
linens or chair surfaces

Results in superficial loss of protective outer

layers of the stratum corneum
 Minimize Friction & Shear
Ensure the head of bed at lowest degree of
elevation (consistent with other medical
conditions & restrictions) no higher then
30 degrees except for short periods of time
– meals
If head of bed is up flex knee gatch slightly
to prevent sliding
Use transfer techniques that reduce shear –
trapeze, transfer board, slider
Use turning sheet or slider

Keep linens flat and free of stray

objects or crumbs

Protect elbows and heels from friction

(transparent films, socks, foam
blocks, heel and elbow protectors,
heel over edge of pillow at all times
in bed)
 Moisture

Primary risk

factor ( especially

from incontinence)

for development

of pressure ulcers
 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
 Moisture Management
Use commercial barriers, barrier films,
transparent dressings
Promote continence
Use quality continence products with quick drying
surface and ability to wick and hold moisture
Avoid use of plastic sheets
Breathable clothing
Keep peri-wound tissue dry
 Protective Skin Care
Peri care with routine incontinence care
Peri wash solutions
Soap and water, pat dry
Zinc protective products – do not need to be
completely washed off ensure surface
layer is cleaned
Barrier skin prep
Moisturise dry skin
 Maximize Nutrition
• Consult dietician as indicated
• Monitor intake
• Provide adequate protein and calories to avoid protein
depletion
• Consider need for supplemental Vitamins (A, C & E,
Zinc)
• Maintain good hydration (1500-2000 mls of hydrating
fluids/day)

Increased metabolic demand for

healing pressure ulcers
 Enhance Mobility and Activity
• Consult PT, OT,
Recreational
Therapist, Activity
Worker as needed

Make use of other

Disciplines – they
enhance care
 Treat the
Wound

Follow
recommendations
outlined in
Care of the wound bed
If no healing or deterioration evident in
6 weeks consult a wound care
specialist – if optimal healing
conditions have been managed
 Treat Patient Concerns
Manage Pain

Provide psychological, emotional, and

financial support (consult social worker if
needed)

Provide patient and family education

 Case Study
38 year old obese female, diabetic, in
hospital due to non adherence to
treatment management at home

large ulcer on
80 % of heel

smokes, alcohol?

Wheel chair
 Case Study
Same lady other heel
initial assessment heel on
readmission
already in hospital to hospital after 8
4 months weeks in home
 Heel Ulcer
Heel ulcer on the same lady and the same
foot

hospital acquired

pulse good

feet warm
 Problems Encountered
1 -Non adherent to non weight bearing when
at home
2 -commercial drug use and increased
smoking at home
3 -depression due to breakdown of
relationship
4 -non adherence to diabetic concerns
5 -renal failure increasing
6 -healing to initial wound good but she
neglected other limbs
7 -did not want responsibility or education –
chatted about anything else
 What would you do ?
In groups

Design assessment/diagnosis

complications

solutions

treatment
 Questions?

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