Assisting With Pressure Ulcers



Assisting With Pressure Ulcers



Key Abbreviation


CMS Centers for Medicare & Medicaid Services



Objectives



• Define the key terms and key abbreviation listed in this chapter.


• Describe the causes and risk factors for pressure ulcers.


• Identify the persons at risk for pressure ulcers.


• Describe the stages of pressure ulcers.


• Identify the sites for pressure ulcers.


• Explain how to prevent pressure ulcers.


• Identify the complications from pressure ulcers.


• Explain how to promote PRIDE in the person, the family, and yourself.



Key Terms








Before defining pressure ulcer, you need to understand these terms.



• Bony prominence—an area where the bone sticks out or projects from the flat surface of the body. The back of the hand, shoulder blades, elbows, hips, spine, sacrum, knees, ankles, heels, and toes are bony prominences (Fig. 25-1, p. 400). These areas also are called pressure points.


image
FIGURE 25-1 Bony prominences (pressure points).
A, The supine position. B, The lateral position. C, The prone position. D, Fowler’s position. E, Sitting position.

• Shear—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. See Chapter 14.


• Friction—the rubbing of 1 surface against another. The skin is dragged across a surface. Friction is always present with shearing.


The National Pressure Ulcer Advisory Panel (NPUAP) defines pressure ulcer as a localized injury to the skin and/or underlying tissue, usually over a bony prominence (Fig. 25-2, p. 401). It is the result of pressure or pressure in combination with shear. Decubitus ulcer, bed sore, and pressure sore are other terms for pressure ulcer.


image
FIGURE 25-2 A pressure ulcer.

The Centers for Medicare & Medicaid Services (CMS) defines 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.



Risk Factors


Pressure is the major cause of pressure ulcers. Shearing and friction are important factors. Risk factors include breaks in the skin and skin breakdown, poor circulation to an area, moisture, dry skin, and irritation by urine and feces.


Unrelieved pressure squeezes tiny blood vessels. For example, pressure occurs when the skin over a bony area is squeezed between hard surfaces (Fig. 25-3). The bone is 1 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. Skin and tissues die.


image
FIGURE 25-3 Tissue under pressure. The skin is squeezed between 2 hard surfaces—the bone and the mattress.

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:



See Focus on Older Persons: Persons at Risk.



Focus on Older Persons


Persons at Risk


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



Pressure Ulcer Stages


In persons with light skin, a red area is the first sign of a pressure ulcer. In persons with dark skin, the skin may have no color change or appear red, blue, or purple. Color does not fade when pressure is applied. The area may feel warm or cool and soft or firm. The person may complain of pain, burning, tingling, or itching in the area. Some persons do not feel anything unusual. Box 25-1 describes pressure ulcer stages. The stages are shown in Figure 25-4.



Box 25-1   Pressure Ulcer Stages




Suspected deep tissue injury: A purple or maroon area of intact skin or a blood-filled blister. Pressure or shear has damaged underlying soft tissue. Involved tissue may be painful, firm, mushy, boggy, warm, or cool. Skin changes may be hard to see in persons with dark skin. See Figure 25-4, A.


Stage 1: Intact skin with redness over a bony prominence. The color does not fade with pressure. In persons with dark skin, skin color may differ from surrounding areas. It may appear pale, blue, or purple. See Figure 25-4, B.


Stage 2: Partial-thickness skin loss (Fig. 25-4, C). The wound may involve a blister or shallow ulcer. An ulcer may appear to be reddish-pink. A blister may be intact or open.


Stage 3: Full-thickness tissue loss (Fig. 25-4, D). The skin is gone. Subcutaneous fat may be exposed. Slough may be present. Slough is dead tissue that is shed from the skin. It is usually light colored, soft, and moist. It may be stringy at times.


Stage 4: Full-thickness tissue loss with muscle, tendon, and bone exposure (Fig. 25-4, E). Slough and eschar may be present. Eschar is thick, leathery dead tissue that may be loose or adhered to the skin. It is often black or brown.


Unstageable: Full-thickness tissue loss with the ulcer covered by slough and/or eschar (Fig. 25-4, F). Slough is yellow, tan, gray, green, or brown. Eschar is tan, brown, or black. The stage (Stage 3 or 4) cannot be determined until enough slough and eschar are removed.


image
FIGURE 25-4 Pressure ulcer stages.
A, Suspected deep tissue injury. B, Stage 1. C, Stage 2. D, Stage 3. E, Stage 4. F, Unstageable.

See Focus on Communication: Pressure Ulcer Stages.



Focus on Communication


Pressure Ulcer Stages


Tell the nurse if you see areas of redness, skin color changes, blisters, or skin or tissue loss. Describe what you see as best as you can. Tell the nurse the site. For example, you can say:




Sites


Pressure ulcers usually occur over bony prominences (pressure points). These areas bear the weight of the body in certain positions (see Fig. 25-1). Pressure from body weight can reduce the blood supply to the skin. According to the CMS, the sacrum is the most common site for a pressure ulcer. However, pressure ulcers on the heels often occur.


The ears also are sites for pressure ulcers. This is from pressure on the ear from the mattress when in the side-lying position. Eyeglasses and oxygen tubing (Chapter 26) also can cause pressure on the ears. A urinary catheter can cause pressure and friction on the meatus. Tubes, casts, braces, and other devices can cause pressure on arms, hands, legs, and feet. A pressure ulcer can develop where medical equipment is attached to the skin.


For people who are obese, pressure ulcers can occur in areas where skin has contact with skin. Common sites are between abdominal folds, the legs, the buttocks, the thighs, and under the breasts. Friction occurs in these areas.

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Nov 5, 2016 | Posted by in MEDICAL ASSISSTANT | Comments Off on Assisting With Pressure Ulcers

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