Pressure Ulcers

Learning Session 2Gillian O Brien

Advanced Nurse Practitioner

Tissue Viability

Naas General Hospital

Pat Mc Cluskey

Advanced Nurse Practitioner

Wound Care

Cork University Hospital Group

6/27/2017

Learning Outcomes (Part 1)

� Special Interest Groups: Spinal Cord Injury (SCI), Maternity, Bariatric, Older Adult, Palliative Care & the Critically Ill Patient

� Risk Factors & Risk Assessment

� Positioning

� Surfaces

Learning Outcomes (Part 2)

� MUST

� SSKIN

6/27/2017

Spinal Cord Injury (SCI)

� SCI occurs with damage to the spinal cord that blocks

communication between the brain & the body. Higher

the SCI, the more dysfunction experienced

� Sensory, motor and reflex messages are affected

� SCIs are complete or incomplete & are based on

whether any movement and sensation occurs at or

below the level of injury

� SCI affects more men than women & young adults

between the ages of 16 and 30

� Each person’s recovery from spinal cord injury is

different6/27/2017

SCI & Risk of Tissue Injury

� Risk of tissue injury increases due to immobility,

decreased sensation, & altered pathophysiology

� Risk of PU development impacts individuals with

SCI at every stage of care

� Receiving acute care in a SCI specific facility at the

time of injury significantly reduces risk of PU

development by the time rehabilitation is

introduced

� If PU develops in acute setting ,the length of stay

becomes significantly longer, prolonging the

recovery period6/27/2017

SCI

SCI patients face a life-long risk of PU development that impacts their daily living

� Development of PU’s perceived as a ‘perpetual danger’

� Constant tension between living a full life and avoiding situations that increases risk of PU development

� The On-going awareness and motivation to prevent PU development considered essential

� Reported barriers in accessing care, services,

resources and support (Jackson et al, 2010)6/27/2017

Maternity Risks

� Epidurals

� Semi recumbent position

� Enlarged uterus + > pressure on pelvis.

� Large amount of fluid present

� Specialist birthing beds with split division

� Thick fluid resistant mattresses (=less 2 way stretch)

� Midwives knowledge of Pressure Ulcer Prevention

6/27/2017

Bariatric Patients

The facts:

Bariatric is the science of providing healthcare for those

who have extreme obesity.

� Weight & distribution of weight throughout the body

are involved in determining a bariatric patient.

� Body Mass Index (BMI) is the most commonly

accepted and consistent language for identifying and

defining bariatric patients

� WHO describe people with a BMI greater than 30 as

obese, greater than 40 as severely obese (WHO,

2000).6/27/2017

Bariatric Patients contd

� Obesity has increased dramatically

� Associated with greater mortality than being

underweight

� Association with PU development is unclear

� Specific features of tissue damage are identified:

maceration, inflammation, tissue necrosis

especially in large, deep skin folds

� Both an increased tissue weight increasing the load

on dependent tissues & fragile lymphatic, vascular

systems can cause vascular necrosis

6/27/2017

Bariatric Patients contd

� Treatment for bariatric & non-bariatric patient is

similar but more challenging for the bariatric

� Cannot always move independently

� Shear & friction often increased

� Increased pressure on the bowel & bladder often

leads to stress incontinence

� Respiration can be compromised leading to

decreased oxygen in the tissues

� Limb oedema can lead to blistering & necrosis and

ulceration can develop

6/27/2017

BMI >40 = risk assessment

with validated scoring tool

Important Considerations:

� Body position

� Repositioning schedules

� Skin care

� Support surfaces

� Suitable equipment from

admission

� Check for bottoming out of

equipment

� Comfortable girth size

Note: Pressure ulcers may

develop in unique locations e.g.

skin folds or areas where

equipment is compressing skin(NPUAP – EPUAP 2009)

6/27/2017

Bariatric Patients

Pressure Ulcers & the Older Adult

• By the year 2050, it is estimated that older individuals will

comprise almost 17% of the global population compared

to 7% today (http://www.census.gov/2013 % in 2003)

• As we age, there is a deterioration in both the structure

of the skin & it’s functional ability. Loss of skin integrity

may result due to epidermal thinning, flattening of the

dermal-epidermal junction, increased cell turnover &

collagen production (Intrinsic factors) coupled with

exposure to environmental factors such as manual

handling /devices/repositioning6/27/2017

� All the measures associated with risk assessment &

SSKIN bundles are equally applicable in the care of

the older adult. In addition:

� Continence attention, barrier products, Atraumatic

dressing products, careful handling all important

considerations

6/27/2017

Pressure Ulcers & the Older Adult

NB

6/27/2017

What happens as we get

older?

� Epidermis becomes thinner, cell production slower, cells become larger and irregular

� Strength and elasticity of the skin affected by collagen changes in the dermis

� Decrease in fibroblasts that are responsible for protein and collagen synthesis

� Decrease in the number of epithelial cells and blood vessels

� Thinning cells do not repair as quickly leading to tissue breakdown and delayed healing

� End of life can be associated with organ system

failure, multiple risk factors can lead to unavoidable

pressure ulcers

� In adults with severe dementia, PU development

has been associated with higher mortality rates

6/27/2017

Pressure Ulcers & Palliative care

Palliative Care &Pressure

Ulcers

� Most commonly

encountered in specialist

palliative care settings.

� Prevalence ranging from

17%-40% depending on

the study.

� Estimated that

approximately 1/3 of

palliative care patients

experience a pressure

ulcer at one time or

another

� Palliative care is focused on

prevention & relieving pain

& discomfort

� Implement SKKIN care

bundles within the context

of comfort & prevention

� Set realistic goals

� Patient & family preference

must be central to all

decision making

Pressure Ulcers & Palliative Care

Patient assessment to include:

� Co-morbid health problems (& combinations of)

� Medications

� Nutritional status

� Risk factors, including immobility & incontinence

� Psychosocial implications

� Environmental resources

� Patient/Family wishes/concerns

6/27/2017

Pressure Ulcers & the Critically Ill Patient

� Represent the sickest patients in the healthcare system

� Reported as the highest among hospitalised patients

(Black et al 2012)

� PU development is an additional burden on an already

compromised system

Risk Factors: Haemodynamic instability, poor tissue

perfusion & oxygenation requiring the use of vasoactive

medications, coagulopathy & the primary risk factors of

their illness such as trauma, emergency surgery,

sepsis.............6/27/2017

This cohort of patients have unique

additional needs in terms of PU prevention

especially if their medical condition precludes

repositioning

6/27/2017

Pressure Ulcers

Critically ill Patient

Pressure Ulcers & the Critically Ill Patient

� Low Air Loss Vs Integrated dynamic (powered), Better

redistribution of weight & fewer PU’s developed (Black

et al 2012)

� Evaluate the need to change the support surface in the

patient with spinal instability, oral-pharyngeal airway,

haemodynamic instability

� Haemodynamic instability preventing repositioning

includes, active fluid resuscitation to maintain blood

pressure, active haemorrhaging, life-threatening

arrhythmia

6/27/2017

Critically Ill Patient contd

� Repositioning: More frequent, small shifts, regularly

monitoring their impact. This will allow some

reperfusion (Brindle et al 2013)

� Resume routine positioning as soon as the patients

condition allows

� Foam cushion under the full length of the calves to

elevate the heels or heel suspension devices (effect

of vasoactive medications)

� Observe closely all pressure areas, occiput, ears,

shoulders, elbows due to the increased risk

� Use all repositioning aids available even to make

small moves

Risk Factors & Risk Assessment

• Aimed at identifying individuals susceptible to PU

development

• Purpose: To target appropriate interventions and

prevent tissue damage

Risk Factors include: Activity/Mobility limitations, SCI,

Fractured hip, Older adult, long-term care facilities,

acutely ill, critical care settings.

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6/27/2017

Key information captured

on risk assessment tools

� Mobility status

� Urinary continence

� Bowel continence

� Feeding assistance

needed

� Pressure ulcer history

� Recent weight loss

� Height & weight

� Skin exam

6/27/2017

Risk

Factors

Mechanical boundary Conditions:

�Magnitude of Load

�Time & Duration of Load

�Type of Load (Shear, pressure, friction)

Susceptibility & Tolerance:

� Properties of Tissue

� Individual Geometry of

tissues/bones

� Individual physiology & repair

� Individual transport & thermal

properties

Internal Strains/Stresses

Damage Threshold

Pressure

Ulcer?

Tissue Tolerance

�Refers to the ability of the skin and underlying

tissue to tolerate exposure to pressure

without adverse effects.

�Each persons tissue tolerance is different.

�Another risk factor affecting the development

of a pressure ulcer.

What

6/27/2017

Tissue Tolerance contd

QUESTION: What happens if a patient is nursed on

an ‘active’ pressure relieving mattress e.g. quattro

plus/acute when the risk of PU development is low?

Their tissue tolerance would reduce putting them at

higher risk for skin breakdown when returning home

or to a normal mattress.

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6/27/2017

Risk Assessment

� Gold Standard = Risk Assessment Tool + Clinical judgement.

� Despite extensive research no consensus has been reached on which risk factors and what number on the scale (cut-off point) are the best predictors of PU development

� Risk assessment tools do however encourage systematic evaluation

6/27/2017

Risk Assessment contd

� Risk assessments should be completed within 6 hours of admission in the hospital setting and at first assessment in the community

� If assessed as ‘at risk’ (Waterlow Score of 15 or > ) then re-assessment is recommended at least weekly. In certain care-settings, daily measurement of risk is recommended e.g. the intensive care setting

Positioning

6/27/2017

Repositioning of patients is as important on alternating

support surfaces as on static surfaces. Fletcher et al. (2015)

Repositioning

� Integral component of pressure ulcer prevention and

treatment;

� Sound theoretical rationale

� Widely recommended and used in practice (lack of robust

evaluations of repositioning frequency and position for pressure ulcer

prevention mean that great uncertainty remains but it does not mean these

interventions are ineffective since all comparisons are grossly

underpowered).

� Current evidence is small in volume and at risk of bias and

there is currently no strong evidence of a reduction in

pressure ulcers with the 30° tilt compared with the

standard 90º position or good evidence of an effect of

repositioning frequency. 6/27/2017

� There is a clear need for high-quality, adequately-

powered trials to assess the effects of position and

optimal frequency of repositioning on pressure

ulcer incidence.

� The limited data derived from one economic

evaluation means it remains unclear whether

repositioning every 3 hours using the 30º ilt is less

costly in terms of nursing time and more effective

than standard care involving repositioning every 6

hours using a 90º tilt (Cochrane 2014, Gillespie et

al)6/27/2017

Repositioning contd

Repositioning contd

� Reposition all patients at risk of or with existing PU’s,

unless contraindicated

� Repositioning & Support surfaces, is it still necessary to

reposition?

� Repositioning schedules, are they outdated? Have they a

value?

� Repositioning aids

� Repositioning Techniques

6/27/2017

Repositioning contd

� Determined by the individual’s tissue tolerance

� Assess skin

� Consider support surface

� Comfort, dignity & functional ability

� Avoid friction & shear

� Avoid positioning on tubes & drains etc

� Avoid positioning on existing tissue damage

� +/- 30 degree tilt

� 24 Hour Approach

� Document6/27/2017

30 Degree Tilt

� Use the 30 degree side-lying

position (right side, left side, back

side) if the patient can tolerate &

medical condition allows

� Avoid lying postures that increase

pressure such as the 90 degree side

lying position or the semi-

recumbent position

� Limit Head of bed elevation to 30

degrees

� Prone position: Check all pressure

areas, appropriate pressure

relieving surfaces6/27/2017

Challenges to Repositioning

TVN Society UK consensus document identify specific

circumstances as being:

� Haemodynamic or spinal instability that may preclude

turning or repositioning

� Patients who are non concordant with repositioning,

refuse assessment and subsequent treatment

6/27/2017

Challenges to Repositioning

contd

� Patients who are following end-of-life pathways and may

not be able to tolerate repositioning as frequently as their

skin may require

� Patients who have not previously been seen by a

healthcare professional

� Patients known to a healthcare professional but an

acute/critical event occurs that affects mobility or the

ability to reposition (Oussey, 2014)6/27/2017

6/27/2017

Assessment

Do we know the cause and can it be eliminated?

Full medical, surgical and social history

� Physical examination to include: factors that may impede healing e.g., impaired perfusion, impaired sensation, systemic infection

� Vascular assessment for extremity ulcers

� Bloods to include Hb, Albumin, Total Proteins, C.R.P.

� Nutritional Assessment

6/27/2017

Assessment contd

� Risk of developing additional ulcers

� Psychological health, behaviour and cognition

� Social support systems

� Functional capacity in regard to positioning, posture

� Surfaces, Aids, Available care

� Individual/Family, Knowledge of existing PU, it’s development, challenges and management to date

Support Surfaces

� Are defined as ‘specialised devices for pressure

redistribution designed for the management of tissue

loads, microclimate, and/or other therapeutic functions’

(National Pressure Ulcer Advisory Panel, 2012)

�

� The term Microclimate refers to the temperature and

moisture at the skins surface where it comes in contact

with a support surface (National Pressure Ulcer Advisory

Panel, 2012)

� Any surface in contact with the skin has the potential to

alter the microclimate. 6/27/2017

6/27/2017

Pressure Ulcer prevention devices

When selecting equipment or positioning patients, consider:

� Postural alignment,

� Distribution of weight,

� Balance , Stability

� Pressure ulcer risk reduction

(Especially important in the sitting position in bed or chair)

Reposition, or where possible teach patient to reposition

themselves to redistribute pressure.

Surfaces (lying)

Support surfaces should be chosen on an individualbasis/personal need

The extent to which pressure is concentrated over smallareas will determine the degree of potential tissue damage

Reactive Support; Powered or non-powered has the abilityto change its load distribution only in response to an appliedload

Active Support; Powered producing alternating pressurethrough mechanical means & has the ability to change itsload distribution with or without an applied load

6/27/2017

Constructed with: Foam, Gel, Fluid, Sand, Air

Powered: to alter the immersion and envelopment

characteristics of the surface to control the

microclimate (heating, cooling, controlling moisture)

or to redistribute pressure

Low Air-Loss: Describes the circulation of air beneath

a water-vapour permeable cover to control the

humidity at the interface between the individual and

the support surface)

Surfaces (lying) contd

Surfaces (lying) contd

Although total bed rest may create a pressure-free wound environment, it has potential complications:

� Muscle wasting & joint contracture

� Loss of bone density

� Respiratory issues

� Malnourishment

� Psychological challenges

� Social isolation

� Cost implications ( loss of income)

Balancing the physical, social, psychological and financial needs is a challenging dilemma

6/27/2017

6/27/2017

Pressure Ulcer prevention

devicesFall into 3 main categories

1. Speciality beds

There are many types including Air Fluidised (large volume of air pumped through particles & induce a fluid-like behaviour), Low Air Loss (Deep & Soft selectively interchanged to allow increased airflow over moist skin

2. Mattresses Replacements

(Powered, non-powered, Hybrid)

3. Overlays

We’ve come a long way.......

6/27/2017

6/27/2017

Support Surfaces for Treatment of

P.U.’s

Alone they neither prevent or heal pressure ulcers

Consider replacing the existing support surface if;

� the patient cannot be repositioned off the ulcer,

� has a pressure ulcer on 2 or more turning surfaces,

� fails to heal or has deterioration of the ulcer despite comprehensive care,

� is at high risk of developing further ulceration

� the existing surface ‘bottoms out’

Before replacing the existing support surface;

� Evaluate the effectiveness of previous and current prevention and treatment plans.

� Continue with the repositioning schedule

� Limit head-of-bed elevation to 30 degrees if patient is on bed rest

� Use the 30 degree tilt

� Use transfer aids for repositioning and remove moving and handling equipment after repositioning

� Increase activity as rapidly as tolerated

6/27/2017

Support Surfaces for Treatment of

P.U.’s

6/27/2017

Choices

� Grade 1 and Grade 2; High-specification foam (Visco-elastic), Hybrid

� Grade 2, 3, 4, Unstageable and Deep Tissue Injury: Support surface should provide enhanced pressure redistribution, shear reduction & microclimate control. E.g. Low Air-Loss,

� Where tissue integrity is deeply compromised and there are multiple sites of ulceration The Air-Fluidised (Sand) Therapy system may be the only appropriate choice

� Selection of support surfaces is complex and cannot

be determined solely on the grade of the ulcer

� Many patients report sleep disturbance from the motor in dynamic surfaces or motion sickness, patient choice is paramount in the decision-making process

� Heels: Float

Other aids include the Heel Suspension Boot, Repose boot, Evolution Patient Positioner

6/27/2017

Choices contd

6/27/2017

Surfaces (Seating)

� Ideally, ischial ulcers should heal in an environment where the ulcers are free of pressure and other mechanical stress

� Total bed-rest may be prescribed which can potentially lead to muscle wasting, respiratory complications (involve Physiotherapist), social isolation

� Balancing physical, social and psychological needs against the need for total off-loading is challenging for both the individual and the health care professional

� Seating cushions must be high-immersion, uniform-loading, distribution cushions (Involvement of O.T.is invaluable)

� The chair should be the right height and width to provide appropriate weight distribution

� Avoid seating an individual erectly if an ischial ulcer exists, use a tilt position

� Restrict sitting time to 60 minutes three times daily (EPUAP, 2009)

6/27/2017

Surfaces (Seating) contd

Surfaces ( Seating) contd

Individualise the selection & periodic re-evaluation of

seating support surfaces & associated equipment for

posture & pressure redistribution with consideration to:

� Body size & configuration

� Effects of posture & deformity on pressure

redistribution

� Mobility & lifestyle needs

� Individual assessment that includes pressure mapping

6/27/2017

Seating Surfaces for SCI

1. Evaluation by a seating professional (access to interfacepressure mapping & thermography)

2. Consider all seating surfaces (e.g. Commodes, toilets,work/travel seating...)

A pressure redistribution cushion must:

� Provide contour, uniform pressure distribution, highimmersion or offloading

� Promote adequate posture and stability

� Permit air exchange to minimise temperature and moistureat the buttock interface

� Provide a stretchable cover that fits loosely on the topcushion surface and is capable of conforming to the bodycontours

No single surface is appropriate for all individuals with SCI

6/27/2017

Seating Surfaces contd

� Centre of pressure displacement is significantly lower

in individuals with SCI than healthy individuals

indicating impaired dynamic sitting stability

� No difference in centre of pressure displacement

between individuals with high or low thoracic SCI

� Significant pressure displacement during forward

leaning and backward leaning positioning for

individuals who had a previous PU

6/27/2017

Seating with existing PU’s

� Tilt / Lean forward when possible & safe (Tilt-in-space,Recline, Standing features in wheelchairs)

� Pressure relief schedules, frequency and duration ofweight shifts

� Avoid elevating the feet as this can increase thepressure in the sacral area

Weigh the risks and benefits of supported sitting versusbed rest against benefits to both physical and emotionalhealth

6/27/2017

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Types of cushions

� Air

� Foam

� Gel

6/27/2017

Air

� Air pumped OR alternating air

� Regular maintenance

� Unstable base

� May require assistance with transfers

6/27/2017

Foam

� Variety of thicknesses

� Light

� No maintenance or adjustment

� Stable cushions

� Replace every 6-9 mths

� Can act as insulation and increase skin temperature

6/27/2017

Gel

� Weight distributed evenly

� Conforms to body shape

� More stable than air

� Conduct heat away from use

� Cleaned easily

� Heavy and difficult to lift from chair

6/27/2017

Mattress and cushion……….

TOGETHER!

“When pressure relieving mattresses are used, their

efficiency is reduced when patients are sitting out

of the bed on non-pressure relieving devices”

(Bliss, 1990)

Off-loading Aids

6/27/2017

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Which stage-Which device?

� Stage 1. Static, Overlay

� Stage 2. Static, Overlay, Alternating

� Stage 3. Alternating/Low air loss.

� Stage 4. Alternating/Low air loss/Air fluidised

+ Reposition..Reposition..Reposition

6/27/2017

Prevention really is the best Intervention

Risk� Risk Assess

� Care Plan

� Interventions

� On-going monitoring

� Re-assessment

Early

Care Plan

Quality

Improvement/

Monitor Program

Daily skin

check

Thank You

6/27/2017

PAUSE

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