Pressure Ulcer Presentation

Brenda Holmes MSN, RNSeptember 7, 2007

Pressure Ulcer Presentation

Objectives Students will be able to:

identify each stage of pressure ulcers. know procedures in preventing pressure

ulcers. to follow through with the care.

Pressure Ulcer Presentation

What do you know about pressure ulcer?

Pressure Ulcer Presentation

Epidermis Dermis Subcutaneous

layer

Pressure Ulcer Presentation

Bony prominence Head, Scapula,

Vertebrae Elbows, Between

knees, Ankles, Heels

Hips, Sacral, Coccyx

Pressure Ulcer Presentation

At risk for pressure ulcer A person that remains in one position

due to inability to move self Old age Poor nutrition and lack of fluids Moisture Cardiovascular or respiratory problems Friction and shearing injuries

Pressure Ulcer Presentation

Types of pressure relieving devices Heel protectors Elbow protectors Bed cradle Footboard Air flow mattress Alternating pressure bed

Pressure Ulcer Presentation

Braden Scale New Stages of Pressure Ulcer

New as of February 2007 (Suspected) Deep Tissue Injury Stage 1 Stage II Stage III Stage IV Unstageable

Pressure Ulcer Presentation

Suspected deep tissue injury Purple or maroon

localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear

Pressure Ulcer Presentation

Stage I Nonblanchable

erythematic Treatment

Repositioning Relieving devices Heel or elbow

protectors Skin barriers

Pressure Ulcer Presentation

Stage 2 Partial thickness

loss of dermis as a shallow crater

Pink wound bed No slough (yellow) May be intact or

open blister

Pressure Ulcer Presentation

Stage III Full thickness

tissue loss Subcutaneous fat

may be visible but bone, tendon, or muscle not exposed

Slough may be present but not the depth of the tissue loss

Pressure Ulcer Presentation

Stage IV Full thickness loss

with exposed bone or tendon

Slough or eschar can be visible in some parts of the wound bed

Can include tunneling or undermining

Pressure Ulcer Presentation

Unstageable Full thickness

tissue loss with base covered by eschar (black, tan, brown, or slough (yellow, green, tan, gray, or brown)

Pressure Ulcer Presentation

Nurses’ responsibility Address issue immediately Start pressure ulcer preventative

measures as soon as MD is notified Turn patient q 2hours Inform dietician if open wound is

present Measure/describe wound on admission

and weekly

Pressure Ulcer Presentation

Nursing Assistant’s responsibility Turn resident/patient every 2 hours Provide peri-rectal care after each incontinent

episode Apply lotion or cream after each incontinent

episode (DO NOT MASSAGE) Report any skin integrity issue to primary care

nurse Assist primary care nurse as needed with

wound care (as set by each facility)

Pressure Ulcer Presentation

Treatments Heel protectors Turn q 2 hours Specialty mattress Creams, ointments, dressings, wound

vac as ordered by MD Nutritional support i.e. dietary consult,

increase protein, vitamin support (Vitamin C and Zinc)

Pressure Ulcer Presentation

Conclusion

PREVENTION

Pressure Ulcer Presentation

ReferenceNational Pressure Ulcer Advisory

Panel (2007). http://www.npuap.orgBlack, J. M. & Black, S. B. (2004).

Deep tissue injury, case study. Wounds from http://www.medscape.com/viewarticle/466563