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Chapter 36 Pressure Ulcers Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Pressure Ulcers (Decubitus Ulcers, Bed Sores, Pressure Sores) A pressure ulcer is a localized injury to the skin and/or underlying tissue. A pressure ulcer usually occurs over a bony prominence. Pressure, shearing, and friction are common causes. Pressure occurs when the skin over a bony area is squeezed between hard surfaces. Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 2 Friction scrapes the skin, causing an open area. Shear is when the skin sticks to a surface while deeper tissues move downward. This occurs when the person slides down in the bed or chair. Unavoidable pressure ulcer Avoidable pressure ulcer Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 3 CMS has standards about pressure ulcers. Nursing centers must evaluate each person’s condition and pressure ulcer risk factors. Identify and implement a comprehensive care plan and measures that meet the resident’s needs and goals. The care plan must include measure to reduce or remove a person’s risk factors. Centers must monitor and evaluate the effect of these measures and revise measures as needed. Residents with a pressure ulcer must receive the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 4 Risk factors include: Breaks in the skin Poor circulation to an area Moisture Dry skin Irritation by urine and feces Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 5 Persons at risk for pressure ulcers are those who: Are bedfast or chairfast Need some or total help in moving Are agitated or have involuntary muscle movements Have loss of bowel or bladder control Are exposed to moisture Have poor nutrition or poor fluid balance Have lowered mental awareness Have problems sensing pain or pressure Have circulatory problems Are older Are obese or very thin Refuse care Have a healed Stage 3 or 4 pressure ulcer Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 6 CMS requires that the person make informed choices. The center and resident must discuss the person’s condition, treatment options, expected outcomes, and problems from refusing treatment. The center must address the person’s concerns and offer options if a certain treatment is refused. Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 7 Pressure ulcer stages Stage 1: The skin is red in persons with light skin. The skin is red, blue, or purple in persons with dark skin. Stage 2: Partial-thickness skin loss; it may involve a blister or shallow ulcer Stage 3: Full-thickness skin loss; subcutaneous fat may be exposed. Slough may be present. Stage 4: Full-thickness tissue loss with muscle, tendon and bone exposed and damaged. Slough and eschar may be present. Unstageable: Full-thickness tissue loss with the ulcer covered by slough and/or eschar. Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 8 Pressure ulcer sites Pressure ulcers usually occur over bony areas called pressure points. Common sites include the sacrum and heel. The ears also are sites for pressure ulcers. In obese people, pressure ulcers can occur in areas where skin has contact with skin. A pressure ulcer can develop where medical equipment is attached to the skin for a prolonged time. Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 9 Prevention Good nursing care, cleanliness, and skin care are essential. The person at risk for pressure ulcers is placed on a support surface that reduces or relieves pressure. TJC and the CMS require pressure ulcer prevention programs. CMS requires use of the Resident Assessment Instrument. Prevention involves identifying persons at risk and implementing prevention measures for them. Treatment The doctor orders wound care products, drugs, treatments, and special equipment to promote healing. Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 10 Protective devices are often used to prevent and treat pressure ulcers. Bed cradles Heel and elbow protectors Heel and foot elevators Gel- or fluid-filled pads and cushions Egg crate–type pads Special beds Pillows, trochanter rolls, foot-boards, and other positioning devices Report and record any signs of skin breakdown or pressure ulcers at once. Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 11 Dressings The nurse decides what dressing to use. The wound must be moist enough to promote healing, but not too moist. For ulcers with drainage, an absorptive dressing is used. Wet-to-dry gauze are sometimes used; they absorb slough, and it is removed when the dressing is removed. Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 12 Complications TJC estimates that ~60,000 people die each year from pressure ulcer complications. Infection is the most common complication. According to the CMS, all Stage 2, 3, and 4 pressure ulcers are colonized with bacteria. Other complications Osteomyelitis Pain Amputation Longer nursing center stays Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 13 Reporting and Recording Report and record any signs of skin breakdown at once. Report and record any signs of pressure ulcers at once. Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 14 Quality of Life The Omnibus Budget Reconciliation Act of 1987 (OBRA), the CMS, and TJC require a care plan for each person. It must address correct skin care. Residents have the right to care that promotes healthy skin and prevents skin breakdown and pressure ulcers. Everyone must keep the person’s skin healthy. Follow the person’s care plan. Be very careful not to injure the skin during care. Treat the person with dignity and respect. Copyright © 2011, 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 15