Pressure Ulcer Survey

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Pressure Ulcer Prevention and Reduction Interventions

Daily Skin Inspection

• Daily skin assessments (watch for any changes in the skin).
• Special support surfaces (examples, air, water, gel, or foam).
• Regular repositioning (keep off bony prominences, encourage mobility, or passive range of motion techniques, daily physical therapy).
• Nutritional support (encourage eating and drinking).
• Skin moisture management (keep the skin moisturized with lotion).

Reference:

Gender, A. (2008). Pressure ulcer prevention and management. Retrieved from http://www.rehabnurse.org/pdf/GeriatricsPressureUlcer.pdf

Skin Moisture Management

Special Support Devices

Nutritional Support

Common Pressure Ulcer Sites

Pressure ulcers occur on areas of the body that experience the most bearable pressure, friction and/or shearing conditions. Paralyzed and bed bound patients are at the highest risk of developing pressure ulcers (Adams, 2010). Patients that are confined to wheelchairs wil most frequently experience pressure ulcers on the body where their wheelchairs tend to cause the most constant pressure which are the arms, back,and shoulders due to friction of the chair and pressing on the wheelchair as they roll (Adams, 2010).

The hips, tailbone, and buttocks are other areas that are at risk of developing pressure ulcers for chair and bed bound patients because of decreased sensation below the waist and the inability to shift positions (Adams, 2010). For bed bound patients the head and ears are common sites for pressure ulcers. For the wheelchair bound patient the legs, ankles, knees, and heels are also at risk of developing pressure ulcers because their legs resting up against the lower portion of the wheelchair for extended periods of time (Adams, 2010). The bed bound patient is also at risk of developing pressure ulcers in these areas due to friction and shearing for sliding in the bed to change position's (Adams, 2010).

Reference:

Adams, A. (2010). Common sites of pressure ulcers. Retrieved from http://livestrong.com/article/125638-common-sites-pressure-ulcers/

Common Pressure Ulcer Sites Diagrams

Photos of Other Wound Types and Skin Injuries

Diabetic Foot Ulcer

Skin Tear

Perineal Dermatitis

Arterial Ulcer

Venous Ulcer

References:
Pictures
Google Images. (2012). Retrieved from https://www.google.com/search?q=google+images&rls=com.microsoft:en-us:IE-Address&ie=UTF-8&oe=UTF-8&sourceid=ie7&rlz=1I7ADRA_enUS378

Other Wounds Types and Skin Injuries

Skin Tears- are traumatic skin injuries that result from external friction and/or shearing due to the separation of the epidermis and dermis skin layers. Skin tears are mostly present on the hands, and upper extremities (London Health Sciences Center, 2009).

Venous Ulcers- are shallow dark red or purple wounds on the lower legs that develops when the veins of the lower legs fail to return blood back toward the heart (Kita, 2009).

Arterial Ulcers- are caused by decreased perfusion to the lower extremities. Arterial ulcers are mostly found on the toes, outer ankle, or where there is pressure as a result of walking or footwear (Boertje, 2010).

Diabetic Ulcers- are ulcers that may occur as a direct result of having diabetes mellitus. Diabetic foot lesions are the cause of more hospitalizations than any other complication associated with diabetes mellitus (Rowe, 2011).

Perineal Dermatitis- is inflammation of the skin around the perineal area, upper thigh, and buttocks that is mostly associated with urinary incontinence (Diver, 2007).


References:

Boertje, J. (2009). Arterial ulcers and wound care: Symptoms, causes, treatments, and risks. Retrieved from http://www.woundsource.com/article/arterial-ulcers-and-wound-care-symptoms-causes-treatments-and-risks

Diver, D.S. (2007). Perineal dermatitis in critical care patients. Retrieved from http://ccn.aacnjournals.org/contents/27/4/42./full

Kita, N. (2009). Venous ulcer. Retrieved from http://plasticsurgery.about.com/od/glossary/g/venous_ulcer.htm

London Health Sciences Center. (2009). Skin tear. Retrieved from http://lhsc.on.ca/Health_Professionals/Wound_Care/skintear.htm

Rowe, V.L. (2011). Diabetic ulcers. Retrieved from http://emedicine.medscape.com/article/460282-overview

Understanding Wound Care: Pressure Ulcers Video

Vohrawoundvideo (2011). Understand wound care: Pressure ulcers. Retrieved from http://www.youtube.com/watch?v=jzu3PSRfY1w

Jeopardy Game

SuperTeacherTools (n.d.). Pressure ulcer review game. Retrieved from http://www.superteachertools.com/jeopardyx/jeopardy-review-game.php?gamefile=131359722

Staging of Pressure Ulcers

                                         Suspected Deep Tissue Injury





When a pressure ulcer materializes it is graded based on he degree of tissue damage. The skin is made up of two respective layers which ae the epidermis and the dermis. The epidermis is the thin and tough outter layer of the skin. It contains no blood vessels and it can renew itself monthly. The dermis is the thick inner layer of the skin that is attached to the underlying tissue of the skin and provides the skin with strength and flexibility (Wound Care Information Network, n.d.).

The dermis layer of the skin consists of hair follicles. Its main function for the skin along with the hair follicles is to preserve fluid and electrolyte balance, protect from infections, sustain the body temperture,and to supply sensation (Wound Care Information Network, n.d.).

Stage I
In lighter toned people appears red and when pressed does not turn white. For darker toned people it may appear to be red, blue, or purple. This area of the skin can be painful, warm, and/or cooler than the surrounding skin.

Stage II
Is the partial thickness loss of the dermis. This outer layer of the skin will blister and/or form a shallow open area with the wound bed appearing to be red pink without slough. It can appeart to look like a blister.

StageIII
Is full thickness tissue loss. The tissue below is damaged with a sore that will look like a shallow crater. Subcutaneous tissue may be visible without seeing the bone, tendon, or muscle.

Stage IV
Appears with full thickness loss to the tissue. The crater is very deep. Deep enough to see bone, tendon, or muscle. Slough and eschar may also be visible.

Unstagable
Is full thickness tissue loss with the base of the ulcer covered with slough (yellow, tan, green, gray, or brown) or eschar that can appear to be black, tan , or brown. This stage of the pressure ulcer cannot be identified until the slough and/or eschar is removed.

Suspected Deep Tissue Injury
Is a localized area of the skin that is discolored and intact. It can appear as a blood filled blister related to the damage of the soft tissue underneath it from pressure and/or shearing.

References:

Wound Care Information Network (n.d.). Classifying or staging pressure ulcers. Retrieved from http://www.stoppain.org/pressureulcers/caregivers_staging.asp

Skin Safety & Prevention of Pressure Ulcers

A skin assessment should be performed for an inpatient based on a standardized skin and/or risk assessment tool such as the Braden scale. A full head to toe skin assessment should be carried out on every patient admitted into an acute care setting it in 6 hours of admission with a reassessment performed every 8-24 hours. A skin care policy and physicians consult should be implemented for skin care orders if a patient is found to be at risk of developing a pressure ulcer or if one already exist. A skin care policy (per facility) should consist of nursing interventions that will decrease or exclude friction, shearing, pressure, moisture, and adding maintenance of adequate nutrition and hydration (Institute of Clinical Systems Improvement, 2007).

All skin/risk assessments, their findings, and the initiation of a skin care policy plan should be documented utilizing a consistent documentation format (per facility). Skin/risk assessments, inspection findings, of the developments of a pressure ulcer should be communicated consistently along with any changes that may occur in the patients skin condition as soon as possible (Institute for Clinical Systems Improvement, 2007).

Reference:

Institute for Clinical Systems Improvement (2007). Skin safety protocol: Risk assessment and prevention of pressure ulcers. Retrieved from http://www.njha.com/qualityinstitute/pdf/226200833420PM63.pdf

Voki

braden scale

How To Detrmine A Patients Risk Level for Pressure Ulcers

The Braden scale is an assessment tool used by healthcare professionals to assess a patients risk for the development of hospital acquired pressure ulcers. The evaluation of the Braden scale is based on six distinct indicators which are sensory perception, moisture, activity, mobility, nutrition, friction and/or shear. The Braden scale consists of six subscales that are scored fro 1-4 with total scores that has a range of 6-23. A Braden score of 15-18 signifies that the patient is at risk for developing a pressure ulcer, a score of 13-14 signifies that the patient is a a moderate risk for developing a pressure ulcer, a score of 10-12 indicates that the patient is at a high risk of developing a pressure ulcer, and a score less than or equal to 9 is an indication that the patient is at a very high risk of developing a presurre ulcer (Ayello, 2011).

Reference:

Ayello, E.A. (2011). Predicting pressure ulcer risk. Retrieved from http://consultgerin.org/uploads/File/trythis/try=this_s.pdf

Prevention and Management of Hospital Acquired Pressure Ulcers

A pressure ulcer is localized damage to the skin and/or the underlying tissue that primarily occurs over a bony prominence, as a direct effect of pressure, or the pressure mixed with shearing and/or friction (National Pressure Ulcer Advisory Panel, 2007).  Pressure ulcers are very painful, uncomfortable, and an expensive complication of being on bedrest.  In most cases pressure ulcers can be averted through proper identification of patients who are at risk along with appropriate use of preventive measures.  The frequency of hospital acquired pressure ulcers is a practical indicator of the quality of care given for inpatients (Perneger et al., 2000). 

Pressure ulcers characterize a very severe problem for patients in the acute care setting, and a very indicative care management challenge for clinicians.  Pressure ulcers primarily affect the elderly and patients that have impaired mobility.  As this population of patients continue to age the incidence of pressure ulcers are likely to increase (Garza et al., 2006).  The cost of treating a bedsore or pressure ulcer in a hospital setting averages right around $43,000 (WoundVision, 2011). 

As nurses we are in the position to be the first line of defense for the prevention and management of hospital acquired pressure ulcers.

References:

Garza, S., Okere, V., Igbinoba, J., Novosad, K., & Pexton, C. (2006). Six sigma and change management: Reducing hospital-acquired pressure ulcers. Retrieved from http://www.gehealthcare.com/euen/services/docs/Reducing_Hospital_Acquired_Pressure_Ulcers.pdf

National Pressure Ulcer Advisory Panel (2007). Pressure ulcer stages revised by NPUAP. Retrieved from http://www.npuap.org/pr2htm

Perneger, T.V., heliot, C., Rae, A.C., Borst, F., & Gaspoz, J.M. (2000). Retrieved from http//:archinte.ama-assn.org/cgi/reprint/158/17/1940.pdf

WoundVision (2011). Pressure ulcer, wound care, and healthcare statistics. Retrieved from http://woundvision.com/statistics