Chapter 34Chapter 34

Pressure UlcersPressure Ulcers

Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

Before defining pressure ulcers, “You need to Before defining pressure ulcers, “You need to understand these terms”understand these terms” Bony prominence—area where the bone sticks out Bony prominence—area where the bone sticks out

or projects from the flat surface of the bodyor projects from the flat surface of the body Shear—when layers of the skin rub against each Shear—when layers of the skin rub against each

other, or when the skin remains in place and other, or when the skin remains in place and underlying tissues move and stretch and tear underlying tissues move and stretch and tear underlying capillaries and blood vesselsunderlying capillaries and blood vessels

Friction—the rubbing of one surface against anotherFriction—the rubbing of one surface against another

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Pressure UlcersPressure Ulcers

Pressure Ulcers (cont’d)Pressure Ulcers (cont’d)

Pressure ulcers are defined by:Pressure ulcers are defined by: The National Pressure Ulcer Advisory Panel The National Pressure Ulcer Advisory Panel

(NPUAP)—a localized injury to the skin and/or (NPUAP)—a localized injury to the skin and/or underlying tissue usually over a bony prominenceunderlying tissue usually over a bony prominence

The Centers for Medicare & Medicaid Services The Centers for Medicare & Medicaid Services (CMS)—any lesion caused by unrelieved pressure (CMS)—any lesion caused by unrelieved pressure that results in damage to underlying tissuesthat results in damage to underlying tissues

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Risk FactorsRisk Factors

Pressure is the major cause of pressure ulcers.Pressure is the major cause of pressure ulcers. Risk factors include breaks in the skin, poor circulation Risk factors include breaks in the skin, poor circulation

to an area, moisture, dry skin, irritation by urine and to an area, moisture, dry skin, irritation by urine and feces.feces.

Skin and tissues die.Skin and tissues die. Friction scrapes the skin, causing an open area.Friction scrapes the skin, causing an open area.

A poor blood supply or an infection can lead to a pressure A poor blood supply or an infection can lead to a pressure ulcer.ulcer.

Shear occurs when the person slides down in the bed or Shear occurs when the person slides down in the bed or chair.chair. Blood vessels and tissues are damaged.Blood vessels and tissues are damaged. Blood flow to the area is reduced.Blood flow to the area is reduced.

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Persons at risk for pressure ulcers are those who:Persons at risk for pressure ulcers are those who: Are bedfast or chairfastAre bedfast or chairfast Need some or total help in movingNeed some or total help in moving Are agitated or have involuntary muscle movementsAre agitated or have involuntary muscle movements Have urinary or fecal incontinenceHave urinary or fecal incontinence Are exposed to moistureAre exposed to moisture Have poor nutritionHave poor nutrition Have poor fluid balanceHave poor fluid balance Have lowered mental awarenessHave lowered mental awareness Have problems sensing pain or pressureHave problems sensing pain or pressure Have circulatory problemsHave circulatory problems Are obese or very thinAre obese or very thin Have a healed pressure ulcerHave a healed pressure ulcer

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Persons at RiskPersons at Risk

Pressure Ulcer StagesPressure Ulcer Stages

Skin color change remaining after pressure Skin color change remaining after pressure is relieved.is relieved. Persons with light skin—a reddened bony areaPersons with light skin—a reddened bony area Persons with dark skin—skin color differs from Persons with dark skin—skin color differs from

surrounding areassurrounding areas The skin may feel warm or cool.The skin may feel warm or cool. The person may complain of pain, burning, The person may complain of pain, burning,

tingling, or itching in the area.tingling, or itching in the area.

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SitesSites

Pressure ulcers usually occur over bony Pressure ulcers usually occur over bony prominences (pressure points).prominences (pressure points). These areas bear the weight of the body in a certain These areas bear the weight of the body in a certain

position.position. According to the CMS, the sacrum is the most According to the CMS, the sacrum is the most

common site for a pressure ulcer. Other sites common site for a pressure ulcer. Other sites include:include: HeelsHeels EarsEars Areas where medical equipment is attached to skinAreas where medical equipment is attached to skin Areas where skin has contact with skinAreas where skin has contact with skin

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Good nursing care, cleanliness, and skin care Good nursing care, cleanliness, and skin care are essential.are essential.

The Joint Commission (TJC) and the CMS The Joint Commission (TJC) and the CMS require pressure ulcer prevention programs.require pressure ulcer prevention programs.

Prevention includes:Prevention includes: Identifying persons at riskIdentifying persons at risk

• Some agencies use symbols or colored stickers as Some agencies use symbols or colored stickers as pressure ulcer alerts.pressure ulcer alerts.

Implementing prevention measures for those at riskImplementing prevention measures for those at risk• Support surfaces are used to relieve or reduce pressure.Support surfaces are used to relieve or reduce pressure.

Following the person’s care plan Following the person’s care plan

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Prevention and TreatmentPrevention and Treatment

The doctor orders wound care products, drugs, The doctor orders wound care products, drugs, treatments, and special equipment to promote treatments, and special equipment to promote healing.healing. The nurse and care plan tell you what to do.The nurse and care plan tell you what to do. Protective devises commonly used include bed cradle, Protective devises commonly used include bed cradle,

heel and elbow protectors, heel and foot elevators, gel or heel and elbow protectors, heel and foot elevators, gel or fluid-filled pads and cushions, eggcrate-type pads, special fluid-filled pads and cushions, eggcrate-type pads, special beds, and other equipment.beds, and other equipment.

The nurse decides what dressing to use.The nurse decides what dressing to use. Wet dressings are used sometimes.Wet dressings are used sometimes. A dressing that absorbs drainage is used if the pressure A dressing that absorbs drainage is used if the pressure

ulcer has drainage.ulcer has drainage.• The dressing absorbs slough. The slough is removed when The dressing absorbs slough. The slough is removed when

the dressing is removed.the dressing is removed.

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Prevention and Treatment (cont’d)Prevention and Treatment (cont’d)

ComplicationsComplications

Infection is the most common complication.Infection is the most common complication. Colonized—the presence of bacteria on the wound Colonized—the presence of bacteria on the wound

surface or in wound tissue. surface or in wound tissue. The person does not have The person does not have signs and symptoms of an infection.signs and symptoms of an infection.

Osteomyelitis—inflammation of the bone and bone Osteomyelitis—inflammation of the bone and bone marrow. This is a risk if the pressure ulcer is over a marrow. This is a risk if the pressure ulcer is over a bony prominence. bony prominence. The person has severe painThe person has severe pain..

Pain management is important.Pain management is important. Pain may affect movement and activity.Pain may affect movement and activity. Immobility is a risk factor for pressure ulcers. It may Immobility is a risk factor for pressure ulcers. It may

delay healing of an existing pressure ulcer.delay healing of an existing pressure ulcer.

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Reporting and RecordingReporting and Recording

Report and record any signs of skin Report and record any signs of skin breakdown or pressure ulcers at once.breakdown or pressure ulcers at once.

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