36. Pressure ulcers


Pressure ulcers


Objectives



Key terms


avoidable pressure ulcer  A pressure ulcer that develops from the improper use of the nursing process


bedfast  Confined to bed


bony prominence  An area where the bone sticks out or projects from the flat surface of the body


chairfast  Confined to a chair


colonized  The presence of bacteria on the wound surface or in wound tissue; the person does not have signs and symptoms of an infection


eschar  Thick, leathery dead tissue that may be loose or adhered to the skin; it is often black or brown


friction  The rubbing of one surface against another


pressure ulcer  A localized injury to the skin and/or underlying tissue usually over a bony prominence; results from pressure or pressure in combination with shear; any lesion caused by unrelieved pressure that results in damage to underlying tissues


shear  When layers of the skin rub against each other; when the skin remains in place and underlying tissues move and stretch and tear underlying capillaries and blood vessels, causing tissue damage


slough  Dead tissue that is shed from the skin; it is usually light colored, soft, and moist; may be stringy at times


unavoidable pressure ulcer  A pressure ulcer that occurs despite efforts to prevent one through proper use of the nursing process


KEY ABBREVIATIONS











CMS Centers for Medicare & Medicaid Services
TJC The Joint Commission

The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure ulcer as a localized injury to the skin and/or underlying tissue usually over a bony prominence (Fig. 36-1). It is the result of pressure or pressure in combination with shear. Prominence means to stick out. A bony prominence is an area where the bone sticks out or projects from the flat surface of the body. The back of the head, shoulder blades, elbows, hips, spine, sacrum, knees, ankles, heels, and toes are bony prominences (Fig. 36-2). Decubitus ulcer, bed sore, or pressure sore are other terms for pressure ulcer.





imageThe Centers for Medicare & Medicaid Services (CMS) defines a pressure ulcer as any lesion caused by unrelieved pressure that results in damage to underlying tissues. According to the CMS, friction and shear are not the main causes of pressure ulcers. However, friction and shear are important contributing factors. Shear is when layers of the skin rub against each other. Or shear is when the skin remains in place and underlying tissues move and stretch and tear underlying capillaries and blood vessels. Tissue damage occurs. Friction is the rubbing of one surface against another. The skin is dragged across a surface. Friction is always present with shearing.


The CMS has standards focusing on pressure ulcers. Some persons are admitted to the center with pressure ulcers. They come from hospitals or from home. According to the CMS, nursing centers must ensure that:



Centers must identify persons at risk for developing pressure ulcers. Some persons are at greater risk than others. And the person’s risk may increase during an illness (cold, flu) or when his or her condition changes. Many pressure ulcers occur within the first 4 weeks of admission to a nursing center. A person at risk can develop a pressure ulcer within 2 to 6 hours after the onset of pressure. The center must develop a comprehensive care plan to meet the person’s needs. The care plan must include measures to reduce or remove the person’s risk factors.


Risk factors


Pressure is the major cause of pressure ulcers. Shearing and friction are important factors. They also cause skin breakdown (Box 36-1) that can lead to a pressure ulcer. Risk factors include breaks in the skin, poor circulation to an area, moisture, dry skin, and irritation by urine and feces. Older and disabled persons are at great risk for pressure ulcers. Their skin is easily injured. Causes include age-related skin changes, chronic disease, and general debility.



Unrelieved pressure squeezes tiny blood vessels. The skin does not receive oxygen and nutrients. Tissues die and a pressure ulcer forms when the skin is starved of oxygen and nutrients for too long. For example, pressure occurs when the skin over a bony area is squeezed between hard surfaces (Fig. 36-3). The bone is one hard surface. The other is usually the mattress or chair seat. Squeezing or pressure prevents blood flow to the skin and underlying tissues. Oxygen and nutrients cannot get to the cells. Involved skin and tissues die.



Friction scrapes the skin, causing an open area. The open area needs to heal. A good blood supply is needed. A poor blood supply or an infection can lead to a pressure ulcer.


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



Persons at risk


Persons at risk for pressure ulcers are those who:



• Are bedfast (confined to a bed) or chairfast (confined to a chair). Pressure occurs from lying or sitting in the same position for too long.


• Need some or total help in moving. Coma, paralysis, or a hip fracture increases the risk for pressure ulcers.


• Are agitated or have involuntary muscle movements. The person’s movements cause rubbing (friction) against linens and other surfaces.


• Have urinary or fecal incontinence. Urine and feces contain substances that irritate the skin and lead to skin breakdown. They are also sources of moisture.


• Are exposed to moisture. Urine, feces, wound drainage, sweat, and saliva expose the person to moisture. Moisture irritates the skin. It also increases the risk of damage from friction and shearing during re-positioning.


• Have poor nutrition. A balanced diet is needed to properly nourish the skin. The risk for pressure ulcers increases when the skin is not healthy.


• Have poor fluid balance. Fluid balance is needed for healthy skin.


• Have lowered mental awareness. The person cannot act (move, change positions) to prevent pressure ulcers. Drugs and health problems affect mental awareness.


• Have problems sensing pain or pressure. These are symptoms of tissue damage. If the person cannot sense pain or pressure, he or she does not know to alert the staff to the symptoms.


• Have circulatory problems. Good blood flow is needed to bring oxygen and nutrients to the cells. Cells and tissues die when starved of oxygen and nutrients.


• Are older. Older persons have thin and fragile skin. Such skin is easily injured. They may have chronic diseases that affect mobility, nutrition, circulation, and mental awareness.


• Are obese or very thin. Friction can damage the skin.


• Refuse care. imageThe person needs proper care to prevent pressure ulcers. The 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. The presence of a “Do Not Resuscitate” order (Chapter 48) does not mean the person is refusing measures to prevent or treat a pressure ulcer. It only means that the person will not be resuscitated in the event of a cardiac or respiratory arrest.


• imageHave a healed pressure ulcer. According to the CMS, areas of healed Stage 3 or 4 pressure ulcers are more likely to recur. See “Pressure Ulcer Stages.”


Pressure ulcer stages


In persons with light skin, a reddened bony area is the first sign of a pressure ulcer. In persons with dark skin, skin color may differ from surrounding areas. The color change remains after the pressure is relieved. The area may feel warm or cool. The person may complain of pain, burning, tingling, or itching in the area. Some persons do not feel anything unusual. Box 36-2 describes pressure ulcer stages.



Box 36-2


Pressure Ulcer Stages


Stage 1 The skin is intact. There is usually redness over a bony prominence. The color does not return to normal when the skin is relieved of pressure. In persons with dark skin, skin color may differ from surrounding areas. It may appear to be a persistent red, blue, or purple. See Figures 36-4, A, p. 568, and 36-5, A, p. 569.


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Nov 5, 2016 | Posted by in MEDICAL ASSISSTANT | Comments Off on 36. Pressure ulcers

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