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Pressure Ulcers
Learning Session 2Gillian O Brien
Advanced Nurse Practitioner
Tissue Viability
Naas General Hospital
Pat Mc Cluskey
Advanced Nurse Practitioner
Wound Care
Cork University Hospital Group
6/27/2017
Learning Outcomes (Part 1)
� Special Interest Groups: Spinal Cord Injury (SCI), Maternity, Bariatric, Older Adult, Palliative Care & the Critically Ill Patient
� Risk Factors & Risk Assessment
� Positioning
� Surfaces
Learning Outcomes (Part 2)
� MUST
� SSKIN
6/27/2017
Spinal Cord Injury (SCI)
� SCI occurs with damage to the spinal cord that blocks
communication between the brain & the body. Higher
the SCI, the more dysfunction experienced
� Sensory, motor and reflex messages are affected
� SCIs are complete or incomplete & are based on
whether any movement and sensation occurs at or
below the level of injury
� SCI affects more men than women & young adults
between the ages of 16 and 30
� Each person’s recovery from spinal cord injury is
different6/27/2017
SCI & Risk of Tissue Injury
� Risk of tissue injury increases due to immobility,
decreased sensation, & altered pathophysiology
� Risk of PU development impacts individuals with
SCI at every stage of care
� Receiving acute care in a SCI specific facility at the
time of injury significantly reduces risk of PU
development by the time rehabilitation is
introduced
� If PU develops in acute setting ,the length of stay
becomes significantly longer, prolonging the
recovery period6/27/2017
SCI
SCI patients face a life-long risk of PU development that impacts their daily living
� Development of PU’s perceived as a ‘perpetual danger’
� Constant tension between living a full life and avoiding situations that increases risk of PU development
� The On-going awareness and motivation to prevent PU development considered essential
� Reported barriers in accessing care, services,
resources and support (Jackson et al, 2010)6/27/2017
Maternity Risks
� Epidurals
� Semi recumbent position
� Enlarged uterus + > pressure on pelvis.
� Large amount of fluid present
� Specialist birthing beds with split division
� Thick fluid resistant mattresses (=less 2 way stretch)
� Midwives knowledge of Pressure Ulcer Prevention
6/27/2017
Bariatric Patients
The facts:
Bariatric is the science of providing healthcare for those
who have extreme obesity.
� Weight & distribution of weight throughout the body
are involved in determining a bariatric patient.
� Body Mass Index (BMI) is the most commonly
accepted and consistent language for identifying and
defining bariatric patients
� WHO describe people with a BMI greater than 30 as
obese, greater than 40 as severely obese (WHO,
2000).6/27/2017
Bariatric Patients contd
� Obesity has increased dramatically
� Associated with greater mortality than being
underweight
� Association with PU development is unclear
� Specific features of tissue damage are identified:
maceration, inflammation, tissue necrosis
especially in large, deep skin folds
� Both an increased tissue weight increasing the load
on dependent tissues & fragile lymphatic, vascular
systems can cause vascular necrosis
6/27/2017
Bariatric Patients contd
� Treatment for bariatric & non-bariatric patient is
similar but more challenging for the bariatric
� Cannot always move independently
� Shear & friction often increased
� Increased pressure on the bowel & bladder often
leads to stress incontinence
� Respiration can be compromised leading to
decreased oxygen in the tissues
� Limb oedema can lead to blistering & necrosis and
ulceration can develop
6/27/2017
BMI >40 = risk assessment
with validated scoring tool
Important Considerations:
� Body position
� Repositioning schedules
� Skin care
� Support surfaces
� Suitable equipment from
admission
� Check for bottoming out of
equipment
� Comfortable girth size
Note: Pressure ulcers may
develop in unique locations e.g.
skin folds or areas where
equipment is compressing skin(NPUAP – EPUAP 2009)
6/27/2017
Bariatric Patients
Pressure Ulcers & the Older Adult
• By the year 2050, it is estimated that older individuals will
comprise almost 17% of the global population compared
to 7% today (http://www.census.gov/2013 % in 2003)
• As we age, there is a deterioration in both the structure
of the skin & it’s functional ability. Loss of skin integrity
may result due to epidermal thinning, flattening of the
dermal-epidermal junction, increased cell turnover &
collagen production (Intrinsic factors) coupled with
exposure to environmental factors such as manual
handling /devices/repositioning6/27/2017
� All the measures associated with risk assessment &
SSKIN bundles are equally applicable in the care of
the older adult. In addition:
� Continence attention, barrier products, Atraumatic
dressing products, careful handling all important
considerations
6/27/2017
Pressure Ulcers & the Older Adult
NB
6/27/2017
What happens as we get
older?
� Epidermis becomes thinner, cell production slower, cells become larger and irregular
� Strength and elasticity of the skin affected by collagen changes in the dermis
� Decrease in fibroblasts that are responsible for protein and collagen synthesis
� Decrease in the number of epithelial cells and blood vessels
� Thinning cells do not repair as quickly leading to tissue breakdown and delayed healing
� End of life can be associated with organ system
failure, multiple risk factors can lead to unavoidable
pressure ulcers
� In adults with severe dementia, PU development
has been associated with higher mortality rates
6/27/2017
Pressure Ulcers & Palliative care
Palliative Care &Pressure
Ulcers
� Most commonly
encountered in specialist
palliative care settings.
� Prevalence ranging from
17%-40% depending on
the study.
� Estimated that
approximately 1/3 of
palliative care patients
experience a pressure
ulcer at one time or
another
� Palliative care is focused on
prevention & relieving pain
& discomfort
� Implement SKKIN care
bundles within the context
of comfort & prevention
� Set realistic goals
� Patient & family preference
must be central to all
decision making
Pressure Ulcers & Palliative Care
Patient assessment to include:
� Co-morbid health problems (& combinations of)
� Medications
� Nutritional status
� Risk factors, including immobility & incontinence
� Psychosocial implications
� Environmental resources
� Patient/Family wishes/concerns
6/27/2017
Pressure Ulcers & the Critically Ill Patient
� Represent the sickest patients in the healthcare system
� Reported as the highest among hospitalised patients
(Black et al 2012)
� PU development is an additional burden on an already
compromised system
Risk Factors: Haemodynamic instability, poor tissue
perfusion & oxygenation requiring the use of vasoactive
medications, coagulopathy & the primary risk factors of
their illness such as trauma, emergency surgery,
sepsis.............6/27/2017
This cohort of patients have unique
additional needs in terms of PU prevention
especially if their medical condition precludes
repositioning
6/27/2017
Pressure Ulcers
Critically ill Patient
Pressure Ulcers & the Critically Ill Patient
� Low Air Loss Vs Integrated dynamic (powered), Better
redistribution of weight & fewer PU’s developed (Black
et al 2012)
� Evaluate the need to change the support surface in the
patient with spinal instability, oral-pharyngeal airway,
haemodynamic instability
� Haemodynamic instability preventing repositioning
includes, active fluid resuscitation to maintain blood
pressure, active haemorrhaging, life-threatening
arrhythmia
6/27/2017
Critically Ill Patient contd
� Repositioning: More frequent, small shifts, regularly
monitoring their impact. This will allow some
reperfusion (Brindle et al 2013)
� Resume routine positioning as soon as the patients
condition allows
� Foam cushion under the full length of the calves to
elevate the heels or heel suspension devices (effect
of vasoactive medications)
� Observe closely all pressure areas, occiput, ears,
shoulders, elbows due to the increased risk
� Use all repositioning aids available even to make
small moves
Risk Factors & Risk Assessment
• Aimed at identifying individuals susceptible to PU
development
• Purpose: To target appropriate interventions and
prevent tissue damage
Risk Factors include: Activity/Mobility limitations, SCI,
Fractured hip, Older adult, long-term care facilities,
acutely ill, critical care settings.
6/27/2017
6/27/2017
Key information captured
on risk assessment tools
� Mobility status
� Urinary continence
� Bowel continence
� Feeding assistance
needed
� Pressure ulcer history
� Recent weight loss
� Height & weight
� Skin exam
6/27/2017
Risk
Factors
Mechanical boundary Conditions:
�Magnitude of Load
�Time & Duration of Load
�Type of Load (Shear, pressure, friction)
Susceptibility & Tolerance:
� Properties of Tissue
� Individual Geometry of
tissues/bones
� Individual physiology & repair
� Individual transport & thermal
properties
Internal Strains/Stresses
Damage Threshold
Pressure
Ulcer?
Tissue Tolerance
�Refers to the ability of the skin and underlying
tissue to tolerate exposure to pressure
without adverse effects.
�Each persons tissue tolerance is different.
�Another risk factor affecting the development
of a pressure ulcer.
What
6/27/2017
Tissue Tolerance contd
QUESTION: What happens if a patient is nursed on
an ‘active’ pressure relieving mattress e.g. quattro
plus/acute when the risk of PU development is low?
Their tissue tolerance would reduce putting them at
higher risk for skin breakdown when returning home
or to a normal mattress.
6/27/2017
6/27/2017
Risk Assessment
� Gold Standard = Risk Assessment Tool + Clinical judgement.
� Despite extensive research no consensus has been reached on which risk factors and what number on the scale (cut-off point) are the best predictors of PU development
� Risk assessment tools do however encourage systematic evaluation
6/27/2017
Risk Assessment contd
� Risk assessments should be completed within 6 hours of admission in the hospital setting and at first assessment in the community
� If assessed as ‘at risk’ (Waterlow Score of 15 or > ) then re-assessment is recommended at least weekly. In certain care-settings, daily measurement of risk is recommended e.g. the intensive care setting
Positioning
6/27/2017
Repositioning of patients is as important on alternating
support surfaces as on static surfaces. Fletcher et al. (2015)
Repositioning
� Integral component of pressure ulcer prevention and
treatment;
� Sound theoretical rationale
� Widely recommended and used in practice (lack of robust
evaluations of repositioning frequency and position for pressure ulcer
prevention mean that great uncertainty remains but it does not mean these
interventions are ineffective since all comparisons are grossly
underpowered).
� Current evidence is small in volume and at risk of bias and
there is currently no strong evidence of a reduction in
pressure ulcers with the 30° tilt compared with the
standard 90º position or good evidence of an effect of
repositioning frequency. 6/27/2017
� There is a clear need for high-quality, adequately-
powered trials to assess the effects of position and
optimal frequency of repositioning on pressure
ulcer incidence.
� The limited data derived from one economic
evaluation means it remains unclear whether
repositioning every 3 hours using the 30º ilt is less
costly in terms of nursing time and more effective
than standard care involving repositioning every 6
hours using a 90º tilt (Cochrane 2014, Gillespie et
al)6/27/2017
Repositioning contd
Repositioning contd
� Reposition all patients at risk of or with existing PU’s,
unless contraindicated
� Repositioning & Support surfaces, is it still necessary to
reposition?
� Repositioning schedules, are they outdated? Have they a
value?
� Repositioning aids
� Repositioning Techniques
6/27/2017
Repositioning contd
� Determined by the individual’s tissue tolerance
� Assess skin
� Consider support surface
� Comfort, dignity & functional ability
� Avoid friction & shear
� Avoid positioning on tubes & drains etc
� Avoid positioning on existing tissue damage
� +/- 30 degree tilt
� 24 Hour Approach
� Document6/27/2017
30 Degree Tilt
� Use the 30 degree side-lying
position (right side, left side, back
side) if the patient can tolerate &
medical condition allows
� Avoid lying postures that increase
pressure such as the 90 degree side
lying position or the semi-
recumbent position
� Limit Head of bed elevation to 30
degrees
� Prone position: Check all pressure
areas, appropriate pressure
relieving surfaces6/27/2017
Challenges to Repositioning
TVN Society UK consensus document identify specific
circumstances as being:
� Haemodynamic or spinal instability that may preclude
turning or repositioning
� Patients who are non concordant with repositioning,
refuse assessment and subsequent treatment
6/27/2017
Challenges to Repositioning
contd
� Patients who are following end-of-life pathways and may
not be able to tolerate repositioning as frequently as their
skin may require
� Patients who have not previously been seen by a
healthcare professional
� Patients known to a healthcare professional but an
acute/critical event occurs that affects mobility or the
ability to reposition (Oussey, 2014)6/27/2017
6/27/2017
Assessment
Do we know the cause and can it be eliminated?
Full medical, surgical and social history
� Physical examination to include: factors that may impede healing e.g., impaired perfusion, impaired sensation, systemic infection
� Vascular assessment for extremity ulcers
� Bloods to include Hb, Albumin, Total Proteins, C.R.P.
� Nutritional Assessment
6/27/2017
Assessment contd
� Risk of developing additional ulcers
� Psychological health, behaviour and cognition
� Social support systems
� Functional capacity in regard to positioning, posture
� Surfaces, Aids, Available care
� Individual/Family, Knowledge of existing PU, it’s development, challenges and management to date
Support Surfaces
� Are defined as ‘specialised devices for pressure
redistribution designed for the management of tissue
loads, microclimate, and/or other therapeutic functions’
(National Pressure Ulcer Advisory Panel, 2012)
�
� The term Microclimate refers to the temperature and
moisture at the skins surface where it comes in contact
with a support surface (National Pressure Ulcer Advisory
Panel, 2012)
� Any surface in contact with the skin has the potential to
alter the microclimate. 6/27/2017
6/27/2017
Pressure Ulcer prevention devices
When selecting equipment or positioning patients, consider:
� Postural alignment,
� Distribution of weight,
� Balance , Stability
� Pressure ulcer risk reduction
(Especially important in the sitting position in bed or chair)
Reposition, or where possible teach patient to reposition
themselves to redistribute pressure.
Surfaces (lying)
Support surfaces should be chosen on an individualbasis/personal need
The extent to which pressure is concentrated over smallareas will determine the degree of potential tissue damage
Reactive Support; Powered or non-powered has the abilityto change its load distribution only in response to an appliedload
Active Support; Powered producing alternating pressurethrough mechanical means & has the ability to change itsload distribution with or without an applied load
6/27/2017
Constructed with: Foam, Gel, Fluid, Sand, Air
Powered: to alter the immersion and envelopment
characteristics of the surface to control the
microclimate (heating, cooling, controlling moisture)
or to redistribute pressure
Low Air-Loss: Describes the circulation of air beneath
a water-vapour permeable cover to control the
humidity at the interface between the individual and
the support surface)
Surfaces (lying) contd
Surfaces (lying) contd
Although total bed rest may create a pressure-free wound environment, it has potential complications:
� Muscle wasting & joint contracture
� Loss of bone density
� Respiratory issues
� Malnourishment
� Psychological challenges
� Social isolation
� Cost implications ( loss of income)
Balancing the physical, social, psychological and financial needs is a challenging dilemma
6/27/2017
6/27/2017
Pressure Ulcer prevention
devicesFall into 3 main categories
1. Speciality beds
There are many types including Air Fluidised (large volume of air pumped through particles & induce a fluid-like behaviour), Low Air Loss (Deep & Soft selectively interchanged to allow increased airflow over moist skin
2. Mattresses Replacements
(Powered, non-powered, Hybrid)
3. Overlays
We’ve come a long way.......
6/27/2017
6/27/2017
Support Surfaces for Treatment of
P.U.’s
Alone they neither prevent or heal pressure ulcers
Consider replacing the existing support surface if;
� the patient cannot be repositioned off the ulcer,
� has a pressure ulcer on 2 or more turning surfaces,
� fails to heal or has deterioration of the ulcer despite comprehensive care,
� is at high risk of developing further ulceration
� the existing surface ‘bottoms out’
Before replacing the existing support surface;
� Evaluate the effectiveness of previous and current prevention and treatment plans.
� Continue with the repositioning schedule
� Limit head-of-bed elevation to 30 degrees if patient is on bed rest
� Use the 30 degree tilt
� Use transfer aids for repositioning and remove moving and handling equipment after repositioning
� Increase activity as rapidly as tolerated
6/27/2017
Support Surfaces for Treatment of
P.U.’s
6/27/2017
Choices
� Grade 1 and Grade 2; High-specification foam (Visco-elastic), Hybrid
� Grade 2, 3, 4, Unstageable and Deep Tissue Injury: Support surface should provide enhanced pressure redistribution, shear reduction & microclimate control. E.g. Low Air-Loss,
� Where tissue integrity is deeply compromised and there are multiple sites of ulceration The Air-Fluidised (Sand) Therapy system may be the only appropriate choice
� Selection of support surfaces is complex and cannot
be determined solely on the grade of the ulcer
� Many patients report sleep disturbance from the motor in dynamic surfaces or motion sickness, patient choice is paramount in the decision-making process
� Heels: Float
Other aids include the Heel Suspension Boot, Repose boot, Evolution Patient Positioner
6/27/2017
Choices contd
6/27/2017
Surfaces (Seating)
� Ideally, ischial ulcers should heal in an environment where the ulcers are free of pressure and other mechanical stress
� Total bed-rest may be prescribed which can potentially lead to muscle wasting, respiratory complications (involve Physiotherapist), social isolation
� Balancing physical, social and psychological needs against the need for total off-loading is challenging for both the individual and the health care professional
� Seating cushions must be high-immersion, uniform-loading, distribution cushions (Involvement of O.T.is invaluable)
� The chair should be the right height and width to provide appropriate weight distribution
� Avoid seating an individual erectly if an ischial ulcer exists, use a tilt position
� Restrict sitting time to 60 minutes three times daily (EPUAP, 2009)
6/27/2017
Surfaces (Seating) contd
Surfaces ( Seating) contd
Individualise the selection & periodic re-evaluation of
seating support surfaces & associated equipment for
posture & pressure redistribution with consideration to:
� Body size & configuration
� Effects of posture & deformity on pressure
redistribution
� Mobility & lifestyle needs
� Individual assessment that includes pressure mapping
6/27/2017
Seating Surfaces for SCI
1. Evaluation by a seating professional (access to interfacepressure mapping & thermography)
2. Consider all seating surfaces (e.g. Commodes, toilets,work/travel seating...)
A pressure redistribution cushion must:
� Provide contour, uniform pressure distribution, highimmersion or offloading
� Promote adequate posture and stability
� Permit air exchange to minimise temperature and moistureat the buttock interface
� Provide a stretchable cover that fits loosely on the topcushion surface and is capable of conforming to the bodycontours
No single surface is appropriate for all individuals with SCI
6/27/2017
Seating Surfaces contd
� Centre of pressure displacement is significantly lower
in individuals with SCI than healthy individuals
indicating impaired dynamic sitting stability
� No difference in centre of pressure displacement
between individuals with high or low thoracic SCI
� Significant pressure displacement during forward
leaning and backward leaning positioning for
individuals who had a previous PU
6/27/2017
Seating with existing PU’s
� Tilt / Lean forward when possible & safe (Tilt-in-space,Recline, Standing features in wheelchairs)
� Pressure relief schedules, frequency and duration ofweight shifts
� Avoid elevating the feet as this can increase thepressure in the sacral area
Weigh the risks and benefits of supported sitting versusbed rest against benefits to both physical and emotionalhealth
6/27/2017
6/27/2017
Types of cushions
� Air
� Foam
� Gel
6/27/2017
Air
� Air pumped OR alternating air
� Regular maintenance
� Unstable base
� May require assistance with transfers
6/27/2017
Foam
� Variety of thicknesses
� Light
� No maintenance or adjustment
� Stable cushions
� Replace every 6-9 mths
� Can act as insulation and increase skin temperature
6/27/2017
Gel
� Weight distributed evenly
� Conforms to body shape
� More stable than air
� Conduct heat away from use
� Cleaned easily
� Heavy and difficult to lift from chair
6/27/2017
Mattress and cushion……….
TOGETHER!
“When pressure relieving mattresses are used, their
efficiency is reduced when patients are sitting out
of the bed on non-pressure relieving devices”
(Bliss, 1990)
Off-loading Aids
6/27/2017
6/27/2017
Which stage-Which device?
� Stage 1. Static, Overlay
� Stage 2. Static, Overlay, Alternating
� Stage 3. Alternating/Low air loss.
� Stage 4. Alternating/Low air loss/Air fluidised
+ Reposition..Reposition..Reposition
6/27/2017
Prevention really is the best Intervention
Risk� Risk Assess
� Care Plan
� Interventions
� On-going monitoring
� Re-assessment
Early
Care Plan
Quality
Improvement/
Monitor Program
Daily skin
check
Thank You
6/27/2017
PAUSE
Budda Mudra are hand gestures to improve physical, spiritual and emotional well being.
Vitarka Mudra create a constant flow of energy and information to attain clarity of mind.
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