Jamie Oelschlaeger, RN-BSN MRICU, St. Luke’s Medical Center Alverno College MSN Program Click here to get started!

Jamie Oelschlaeger, RN-BSNMRICU, St. Luke’s Medical Center

Alverno CollegeMSN Program

Click here to get started!

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answer box located on the slide

Stage I

Stage III Stage IV Deep Tissue Injury

Unstageable Ulcers

Risk Factors

Stage II

Nursing Interventions

Case Study

Commonly Affected Areas

Integumentary Review

Pathophysiology of Integumentary System

Introduction to Pressure Ulcers

Role of Genetics

Role of Stress Response

Role of Inflammation

By the end of this presentation, the learner will: Identify and differentiate the different

stages of pressure ulcers Understand the difference between

pressure ulcers, deep tissue injury, and unstageable ulcers

Identify risk factors associated with the development of pressure ulcers

Largest organ of human body

Protective function Regulates

temperature with in the body

Storage for water and fat

Prevents loss of water Prevents bacterial

invasion

The Ohio State University Medical Center (n.d.) Image provided by Microsoft clipart

Skin is composed of 3 layers: Epidermis

▪ Outer most layer▪ Prevents bacteria from

penetrating▪ Prevents loss of water

Dermis▪ Middle layer▪ Contains blood vessels,

sweat glands, and nerves Subcutis

▪ Inner most layer▪ Contains collagen and fat ▪ Regulates body temperature

The Ohio State University Medical Center (n.d.) Picture used for education purposes from the

National Pressure Ulcer Advisory Panel (200&

The epidermis thins Changes in connective

tissue result in less elasticity and strength

Blood vessels in dermis become fragile

The subcutaneous layer thins

Reduced sensation of touch, pressure, temperature

U.S. National Library of Medicine (2011) MedicineNet (2011) Web MD (2011) Picture provided by Microsoft clipart

Skin becomes vulnerable to injury

Thinning skin and loss of subcutaneous tissue decrease protection

Increased possibility of blood vessel rupture

U.S. National Library of Medicine (2011) MedicineNet (2011) Web MD (2011) Picture provided by Microsoft clipart

The subcutaneous layer of the skin thins with aging.

True

Right on!

False

No! A normal part of aging in skin includes thinning of the subcutaneous layer of skin.

A pressure ulcer is an area of tissue damage that occurs when the skin and tissues are compressed between bones and a surface which has direct contact with the body

Occurs most frequently over a bony prominence

Classified into four stages based on appearance

The AGS Foundation for Health and Aging (2011) National Pressure Ulcer Advisory Panel (2007)

Skin is intact NON-BLANCHABLE

redness present over in localized area over bony prominence

Affected area may be: Painful Firm Warmer

National Pressure Ulcer Advisory Panel (2007) Picture used for education purposes from the

National Pressure Ulcer Advisory Panel (2007)

Loss of partial thickness to dermis

Shallow or open area Pink and red wound bed Slough is not present Affected area will be:

Shiny or dry No slough or bruising

National Pressure Ulcer Advisory Panel (2007) Picture used for educational purposes from

the National Pressure Ulcer Advisory Panel (2007)

Good Job!

Try Again! This ulcer does not penetrate

beyond the dermis!

No! This ulcer is not

purple/maroon in

appearance!

Try again! This ulcer is not intact!

I

IV

II

Deep Tissue Injury

Click the link below to view the pressure ulcer from Arnold (2007)!

http://www.snjourney.com/Images/pustage2.gif

Loss of partial thickness to dermis

Shallow or open area Pink and red wound bed Slough is not present Affected area will be:

Shiny or dry No slough or bruising

National Pressure Ulcer Advisory Panel (2007) Picture used for educational purposes from the


Full thickness tissue loss Exposed bone, tendons,

and/or muscle Slough or eschar may be

present Affected area may

include: Undermining Tunneling

National Pressure Ulcer Advisory Panel (2007) Picture used for educational purposes from the


Try again! This ulcer has

more than just a open pink wound bed!

Perfect

Nice try! This ulcer does not expose tendon

or bone!

Not this one! This ulcer

does not have a necrotic wound bed

II

III

IV

Unstageable

Click the link below to view the pressure ulcer from the University of Washington (2011)! http://msktc.washington.edu/images/stage_3_Merck.jpg

Skin intact or blood-filled blister

Localized area purple or maroon in color

Underlying soft tissue affected

Affected area may be: Painful Firm Boggy Warmer

National Pressure Ulcer Advisory Panel (2007) Used for educational purposes from the National

Pressure Ulcer Advisory Panel (2007)

Full thickness tissue loss

Base of ulcer covered by slough and/or eschar

Once slough and/or eschar is removed, the ulcer can be staged

National Pressure Ulcer Advisory Panel (2007) Used for educational purposes from the


Try again! This ulcer does not have an open wound bed!

Not this one! This ulcer does not penetrate

beyond the dermis!

Try again! This ulcer is not purplish in

appearance!

Correct!

II

III

Deep Tissue Injury

Unstageable

Click the link below to view the pressure ulcer from Medscape (2011)!

http://img.medscape.com/pi/emed/ckb/rehabilitation/305143-317514-319284-1714350.jpg

Increased pressure, moisture, friction and shear damage underlying tissues of skin

Damaged tissue releases prostaglandins and leukotrienes

WBC collect to the site of injury

Vasodilation occurs at the site

Increased venule permeabilty occurs with in the venules

Porth (2005) Picture provided by Microsoft clipart

Exudate leaks out of the venules and into the surrounding tissue

Decreased blood volume to site of injury

Tissues swell causing edema

Pressure on nerves cause pain

Pressure ulcers develop as a result

Inflammation is the first sign of pressure ulcer development!


Inflammation does not play a role the development of pressure ulcers.

True False

That is correct!Try Again! The infla

mmatory response play a large role in pressure ulcer development

There is no genetic predisposition in developing pressure ulcers

Genetic disorders and diseases can increase risk of pressure ulcer development though: Interference with healing Increased fragility with in

blood vessels and skin Lack of sensation in

limbs


Diabetes is a genetic disease that can cause neuropathy over time and result in loss of sensation in limbs

Loss of sensation can lead to an inability to feel temperature and pressure increasing the risk of pressure ulcers to develop

Peripheral vascular disease is a genetic disorder that causes blood vessel constriction or occlusion decreasing blood flow to affected area

Loss of blood flow causes a decrease in oxygen and nutrients which leads to cell death and increase pressure ulcer risk

American Diabetes Association (2010) Columbia University Medical Center Department of Surgery

(2011) Picture provided by Microsoft clipart

Cerebral Palsy and muscular dystrophy are examples of genetic disorders that cause physical disabilities which can result in paralysis of limbs

Paralysis leads to the inability to move limbs voluntarily

Lack of movement increases risk of pressure, friction, and shear on skin

Pressure ulcers can develop as a result

National Institute of Neurological Disorders and Stroke (2010)


Diabetes can cause neuropathy which results in loss of sensation, inability to sense temperature, and pressure.

True False

That is correct! Try again! Neuropat

hy does result in loss of sensation, pressure, and temperature!

Under stress, the sympathetic nervous system responds

Epinephrine and norepinepherine are released into the blood stream and attach to receptor molecules on the surface of cells

Alpha 1 receptors cause decreased blood flow to skin

Sweating often occurs Beta 1 receptors increase

the metabolic rate Fat stores release fat into

blood stream


Decreased blood flow to skin results in lack of nutrients and oxygen

Sweating increases moisture and risk of friction and shear

Release of fat into the blood stream may decrease protective layer for underlying tissues


Sweating increases moisture and the risk of friction and shear.

True

Right on!

False

No! Sweating does cause additional moisture which increases friction and shear

Pressure on bony prominences restrict blood flow to vulnerable areas

Restricted blood flow decreases oxygen and nutrients

Cell death can occur at area if pressure is not relieved

Mayo Foundation for Medical Education and Research (2011)

Porth (2005)

Elbows Hips Ankles Shoulder blades Back or side of the

head Rim of ears Heels Toes Bridge of nose Sacrum Coccyx

Bedridden or wheelchair bound Increased risk of pressure on bony

prominences and decreased blood flow to vulnerable areas

Aging The epidermis thins and blood vessels become

more fragile Fragile skin

Increased risk of shearing and tearing of skin Urinary or bowel incontinence

Causes skin breakdown and increased moisture

Malnourishment Lack of vitamins and nutrients prevent healing

Smoking Nicotine reduces oxygen level in blood

and impairs circulation

Mayo Foundation for Medical Education and Research (2011) Porth (2005) Picture provided by Microsoft clipart

Decreased mental awareness Mental inability to shift weight to

relieve pressure appropriately Weight loss

Lower fat stores decreases protective layer for underlying tissue

Paralysis Lack of limb movement increases

risk of pressure on vulnerable areas Vascular disease

Increased fragility of blood vessel rupture and decreased blood flow with in vessels

Diabetes Loss of sensation from neuropathy

and poor wound healing



High activity levels can result in the development of pressure ulcers.

True False

No! Higher levels of activity are encouraged! Increased blood flow to different parts of the body increases tissue oxygenation and delivery of nutrients.

Correct!

Turn bed bound patients every 2 hours

Encourage patients to shift weight in chair every 15 minutes

Repositioning relieves pressure on vulnerable bony prominences


U.S. National Library of Medicine (2010) Picture provided by Microsoft clipart

Use pressure alleviating mattresses and pads

Use pillows or foam wedges to prevent contact with bony prominences



Apply moisture barriers and protective films to prevent moisture and skin breakdown

Apply protective, pressure alleviating dressings to open wounds



Encourage fluid intake to maintain skin integrity

Encourage a diet rich in protein, vitamins, and minerals to promote healing

Encourage daily exercise to increase blood flow to skin



Pressure alleviating mattresses are not helpful in pressure ulcer prevention.

True False

No! Pressure alleviating mattresses play a key part in pressure ulcer prevention!

That is correct!

Mr. H, a 75 year old male, is admitted to the ICU from the OR status post cholecystectomy. His past medical history includes: diabetes, peripheral vascular disease, and currently smokes 2 packs per day.Picture provided by Microsoft clipart

Mr. H experienced a number of complications during the case which extended his surgery to 8 hours. Because of his critical status, the physician ordered Mr. H to remain intubated overnight, NPO, and strict bed rest for the first 24 hours post-op.Picture provided by Microsoft clipart

You are the nurse taking care of Mr. H 24 hours after his surgery. He remains on the ventilator and NPO but is off bed rest. You walk into the room to perform your assessment.

Picture provided by Microsoft clipart

As you are turning Mr. H onto his side, you notice an area on his coccyx that looks like this:

Click the link below to view the pressure ulcer from Medscape (2011)!

http://img.medscape.com/article/715/969/715969-fig1.jpg

How would you describe the ulcer you assessed on Mr. H?

Skin IntactLocalized

Non-blanchable erythema

Skin IntactLocalized

Purple/Maroon appearance

Skin openedLocalized

Wound bed pink

Not this one! The ulcer does not have non-

blanchable erythema

Perfect!

Try again! The ulcer is not open with a pick wound

bed

Based on your assessment findings, how would you stage the ulcer?

IDeep Tissue

InjuryII

Correct!

Try Again!It is not a stage II

Not this one! This is not a

stage I

What risk factors make Mr. H more prone to developing pressure ulcers?

Smoking history

Good Job!

Diabetes

Yes!

CPOD

Not a risk factor!

Pancreatitis

Not this one!

Bed ridden

Right On!

PVD

Correct!

What nursing interventions could have been executed to prevent Mr. H from developing an injury?

Turning every 2 hours

Lying supine

continuously

Applying moisture barrier cream

Using a pressure

alleviating mattress

Correct!

Perfect!

You got it!

Sorry! Lying in one position

continuously is a common cause

of pressure ulcers!

AGS Foundation for Health in Aging, The. Pressure ulcers (bed sores). Retrieved February 2, 2011 from http://www.healthinaging.org/agingintheknow/chapters_ch_trial.asp?ch=30American Diabetes Association. (2010). Genetics of diabetes. Retrieved April 5, 2011 from http://www.diabetes.org/diabetes-basics/genetics-of-diabetes.htmlColumbia University Medical Center Department of Surgery. Peripheral vascular disease: Cutting edge therapies and studies at New-York Presbyterian hospital. Retrieved March 31, 2011 from http://www.columbiasurgery.org/news/healthpoints/2009_fall/p3.html Long, M.A. (2007). New and improved: 2007 pressure ulcer definitions. Retrieved April 13, 2011 from SNJourney Web Site: http://www.snjourney.com/ClinicalInfo/Systems/Intrgum/newstagepu.htm Mayo Foundation for Medical Education and Research. (2011) Bed sores (pressure sores). Retrieved February 10, 2011 from http://www.mayoclinic.com/print/bedsores/DS00570/DSECTION=all&METHOD=print MedicineNet. (2011). The effects of aging on your skin. Retrieved March 20th 2011 from http://www.medicinenet.com/script/main/art.asp?articlekey=43078 Medscape. (2011). The Unavoidable Pressure Ulcer: Taking a Stand: Avoidable and Unavoidable Pressure Ulcers. Retrieved April 13, 2011 from http://img.medscape.com/article/715/969/715969-fig1.jpgMedscape. (2011). Pressure Ulcers, Nonsurgical Treatment and Principles. Retrieved April 13th, 2011 from http://img.medscape.com/pi/emed/ckb/rehabilitation/305143-317514-319284-1714350.jpg

National Institute of Neurological Disorders and Stroke. (2010). NINDS cerebral palsy information page. Retrieved March 15, 2011 from

http://www.ninds.nih.gov/disorders/cerebral_palsy/cerebral_palsy.htm National Institute of Neurological Disorders and Stroke. (2010). NINDS muscular dystrophy information page. Retreived from http://www.ninds.nih.gov/disorders/md/md.htmNational Pressure Ulcer Advisory Panel. (2007). Pressure ulcer stages revised by NPUAP. Retrieved February 28, 2011 from http://www.npuap.org/pr2.htm Ohio State University Medical Center. (n.d.) Anatomy of the skin. Retrieved March 23,

2011 from http://medicalcenter.osu.edu/patientcare/healthcare_services/skin_conditions/anatomy_skin/Pages/index.aspx Porth, C.M. (2005). Pathophysiology.University of Washington. (2011). Skin care and pressure sores. Retrieved April 13, 2011 from http://msktc.washington.edu/images/stage_3_Merck.jpg U.S. National Library of Medicine. (2010). Diabetic neuropathy. Retrieved March 5, 2011 from http://www.nlm.nih.gov/medlineplus/ency/article/000693.htm U.S. National Library of Medicine. (2010). Pressure ulcer. Retrieved February 15, 2011

from http://www.nlm.nih.gov/medlineplus/ency/article/007071.htm Web M.D. (2011). The effects of aging on skin. Retrieved March 22, 2011 from http://www.webmd.com/skin-beauty/guide/cosmetic-procedures-agingskin

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Jamie Oelschlaeger, RN-BSN MRICU, St. Luke’s Medical Center Alverno College MSN Program Click here to get started!