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

 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.

INTRODUCTION

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

 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

WHAT IS PRESSURE ULCER

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

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

Vulnerable groups

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

RISK FACTORS

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 ULCER

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

RISK ASSESMENT TOOL

The 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 nutrition activity friction & shearing Total score=23points, adult with 18 points or less is at risk

Norton pressure area risk assessment form scale

General physical condition mental state activity incontinence mobility 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 sims 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.

 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

EVIDENCE BASE PRACTICE

 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

WHEN AN ULCER IS FORMED

PRESSURE ULCER SCALE FOR HEALING (PUSH TOOL)

LENGTH X WIDTH In 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 EXUDATE AMOUNT 0 none 1 light

7 4.1-8.0

8 8.1-12.1

10

Sub score

12.1-24.0 >24.0 Sub score

2 3 moderate heavy

TISSUE TYPE

0 closed

1 epithelial tissue

2 granulati on tissue

3 slough

4 necrotic issue

Sub score

 ASSESSMENT NURSING DIAGNOSIS

NURSING MANAGEMENT

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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