Tips for Keeping it Together

Estella Boger

May 2011

Why Prevent Pressure Ulcers

• Cause Pain

• Interfere with ambulation & rehabilitation

• Result in Osteomyelitis

• Cause cellulitis and septicemia

• Result in amputation

• Take 2-12+ months to heal

• Result in unnecessary healthcare costs – $8.5

billion spent annually on pressure ulcers

Result in litigation

Pressure Ulcer

• A pressure ulcer is a 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.

• Results in vascular insufficiency, tissue anoxia

and cell death

NPUAP definition as of February 2007

Pressure Ulcers

Possible causes include

- not repositioning the patient

- patient sliding down in bed

- laying on tubing or pieces of equipment

- TEDS, Jobst stockings, tubigrip

Contributing Factors

Co-morbid condition - Medical diagnoses, pain,

Patient nutrition

Mobility status – Immobility is the most significant risk factor. Patients who can’t reposition themselves are at high risk

Incontinence – moisture from incontinence macerates skin. Fecal incontinence more important risk factor than urinary incontinence.

Which is the most important risk factor for

pressure ulcers?

A) Fecal incontinence

B) Malnutrition

C) Diabetes

D) Immobility

D) Immobility

Patient profile

64 year old female

Co-morbid conditions: Diabetes mellitus, Fibromyalgia, Osteoarthritis, Spinal stenosis, Chronic pain, Depression

Hospitalized due to falls

Frequently refused to be repositioned due to pain

What would you call this?

A) Ecchymosis

B) Stage 3 pressure ulcer

C) Suspected deep tissue injury

D) Incontinence associated dermatitis

C) Suspected Deep Tissue Injury

There is also a stage 2 pressure ulcer on the coccyx.

How do we prevent this? Start with assessment

Initial and ongoing

Several pressure ulcer prediction scales are available – Braden, Norton

Where to Look - Pressure Check pressure points

- Heels

- Ankles, outer and inner

- Hips

- Coccyx/sacrum/buttocks

- Ischial areas

- Spinous processes

Where to Look - Pressure - Shoulder blades - Back of head - Ears, especially the tops if patient has oxygen by cannula - Elbows - Skin on legs and feet of patients with TED hose, Jobst Stockings or tubigrip on the lower extremities

Interventions

Reposition the patient regularly - every 2-4 hours on a pressure reducing mattress and at least every 2 hours on a nonpressure reducing mattress. This is the most important intervention.

Use of pressure reducing mattresses – this does not replace repositioning but is an adjunct treatment

Minimize friction and shear by keeping skin clean and dry, keeping head of bed below 30 degrees, using lift sheets to turn patient

Interventions

Avoid using foam donuts or rings – they concentrate pressure on the surrounding tissue

Avoid sheepskin for pressure reduction – it’s comfortable but doesn’t reduce pressure. The same can be said for eggcrate cushions and mattresses

Maintain adequate nutrition – your facility dietition can be very helpful with this

What is the most important intervention for preventing pressure ulcers?

A) Repositioning the patient

B) Special mattress

C) Nutritional supplementation

D) Medication

A) Repositioning the patient A special mattress could help.

Optimizing nutrition could also help.

If the patient has quite a bit of pain, pre-medication with an analgesic might be helpful.

References

Guideline for Prevention and Management of Pressure Ulcers. WOCN Society. 2003.