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Ann Leland, APRN, CNP, DNP Instructor, college of surgery

leland.ann@mayo.edu

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Pressure ulcers

Wednesday-Saturday, October 19-22, 2016 Sawgrass Marriott Hotel • Ponte Vedra Beach, Florida

Mayo School of Continuous Professional Development

2nd Annual Inpatient Medicine for NPs & Pas:

Hospital Care from Admission to Discharge

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Learning objectives: • Discuss definition of a pressure ulcer • Review pressure ulcer staging • Discuss management/treatment of a pressure

ulcer utilizing a case study

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Pressure ulcer “injury” definition

http://www.npuap.org/documents/PU_Definition_Stages.pdf

• A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

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Most common locations **Remember devices & equipment **Must be an area affected by pressure

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Case study • Mr. Pressure-70 yom pt who is

wheelchair bound. Presents with sepsis and multiple pressure ulcers.

• Chronic stage IV left hip pressure ulcer with evidence of osteomyelitis

• Stage III coccyx pressure ulcer

• Unstageable left heel pressure ulcer

• Stage III right heel pressure ulcer

• Unstageable R lateral 5th metatarsal pressure ulcer with osteomyelitis

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Pressure ulcer stages indicate:

A. How likely the ulcer is to heal

B. The underlying structures involved in the ulcer

C. How long the ulcer has been present

D. All of the above How

likely

the u

lcer is

...

The und

erlyin

g stru

ct...

How lo

ng the u

lcer h

..

All of th

e abo

ve

0% 0%0%0%

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Pressure ulcer stages indicate:

A. How likely the ulcer is to heal

B. The underlying structures involved in the ulcer

C. How long the ulcer has been present

D. All of the above

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Pressure ulcer staging • Staging is used to

describe a pressure ulcer including the structures involved.

• Structures include: epidermis, dermis, subcutaneous fat, tendon, muscle and bone.

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Deep Tissue Injury • Purple or maroon

localized area of discoloration.

Highlights: 1. May be blister 2. Over pressure point 3. Evolution generally

rapid

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Category/Stage 1 • Intact skin with non-

blanchable erythema. Highlights:

1. Over pressure point 2. Generally associated

with pain and mild induration

3. Indicative of person “at risk”

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Category/Stage 2 • Partial thickness loss of

dermis. Shallow open ulcer.

Highlights: 1. Shallow ulcer without

slough or bruising 2. Over pressure point 3. Should NOT be used to

describe skin tears, tape burns or maceration

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Category/Stage 3 • Full thickness tissue loss,

subcutaneous fat may be visible

Highlights: 1. Over pressure point 2. No bone, tendon or muscle

exposed/palpable 3. May include undermining

and tunneling

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Category/Stage 4 • Full thickness tissue loss

with exposed bone, tendon or muscle. Slough or eschar usually present.

Highlights: 1. Over pressure point 2. Osteomyelitis probable 3. Often includes

undermining & tunneling.

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Unstageable • Full thickness tissue loss in

which the base of the ulcer is covered by slough/eschar

Highlights: 1. Over pressure point 2. Any eschar on heels should

be evaluated by vascular medicine or podiatry

3. Stage cannot be determined until slough removed

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Pre-op dimensions 1x 0.5 Post-op 3 x 5 x 6 cm Ischial Unstageable

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Pressure ulcer patient assessment • Perform a thorough skin assessment w/in 8

hours of admission, prior to discharge and daily depending on risk.

• Stage 3 & 4 pressure ulcers are reportable to the department of health.

https://www.icsi.org/_asset/6t7kxy/pressureulcer.pdf http://www.health.state.mn.us/patientsafety/ae/pufacts.html

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Identification is the Key!! What stage is this ulcer?? (Hint: this is patients hip/greater trochanter)

A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable F. No idea!

Stage 1

Stage 2

Stage 3

Stage 4

Unstag

eable

No idea

!

17% 17% 17%17%17%17%

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Identification is the Key!! What stage is this ulcer?? (Hint: this is patients hip/greater trochanter)

A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable F. No idea!

Stage 1

Stage 2

Stage 3

Stage 4

Unstag

eable

No idea

!

17% 17% 17%17%17%17%

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Management

• Surgical debridement is the gold standard for unstageable and infected pressure ulcers.

• Bedside debridement is indicated in a number of cases:

• Comfort level of the wound provider • Safety of the procedure at the bedside • Appropriate analgesia is available • Wound is amenable to more superficial debridement

(structures easily identified)

• Enzymatic debridement is also an option.

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Case study Chronic stage IV left hip pressure ulcer with evidence of osteomyelitis

Risk Factors:

Wheelchair bound

> 30 lb weight loss in prior 10 months

Non-communicative (unable to report pain, need to reposition)

Chronic kidney disease

Severe debility

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What do you want to do for treatment of this Category/Stage IV ulcer?

A. Offload the area B. Nutrition evaluation C. Operative debridement D. Improve sepsis E. All of the above F. None of the above

Offloa

d the a

rea

Nutritio

n evalu

ation

Operativ

e deb

ridem

ent

Impr

ove s

epsis

All of th

e abo

ve

None o

f the a

bove

0% 0% 0%0%0%0%

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What do you want to do for treatment of this Category/Stage IV ulcer?

A. Offload the area B. Nutrition evaluation C. Operative debridement D. Improve sepsis E. All of the above F. None of the above

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Dressing management • Choose your dressing based on a number of

items: • Appropriate for moisture control (absorptive) • Appropriate to control bacterial burden • Ease of change/replication at home • Protective of surrounding skin • Comfort

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Prevention measures

• Minnesota department of health has implemented the new “Turning clock” to minimize supine positioning.

• Accurate risk assessment

• Skin assessment

• Timely use of support surfaces

• Evidence based incontinence skin care

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Questions & Discussion