PRESSURE ULCER PREVENTION & SKIN CARE

Presented by: Nancy A Windle RN

A pressure ulcer is considered an injury that is caused by unrelieved pressure damaging the skin and underlying tissue.

Unrelieved pressure on the skin squeezes tiny blood vessels, which supply the skin with much needed nutrients and oxygen. When the skin is starved for too long, the tissue dies and a pressure ulcer forms.

Ulcers are common in 9% of the people in hospitals, 3 to 12% in nursing homes and 3 to 14% of people being cared for at home. People transferred from hospitals to nursing homes are particularly vulnerable, with 10 to 35% having sores when they are admitted to the nursing home.

Ulcers can lead to severe medical complications, including bone & blood infections, infectious arthritis, holes below the wound that burrow into bone or deeper tissues, and a scar carcinoma, a form of cancer that develops in scar tissue.

Ulcers form where the weight of the person’s body presses the skin against the firm surface of a bed or chair. In

people confined to bed, ulcers are most common over the

HipSpine

Lower backShoulder blades

ElbowsHeelsEars

Back of head

In people who sit in a wheelchair or geri chair ulcers are more common on the

Lower backButtocks

LegsBack of knees

Elbows

This pressure from prolonged laying or sitting temporarily cuts off the skin’s blood supply. This injures skin cells and can cause them to die. Unless the pressure is relieved and blood flows to the skin again, the skin soon begins to show signs of injury.At first, there may only be a patch of redness. If this red patch is not protected from additional pressure, the redness can form blisters or open sores.In severe cases, damage may extend through the skin and create a deep crater that exposes muscle or bone.Muscle is even more prone to severe injury from pressure than skin. A mild injury to the skin may cover a deeper, more pronounced injury to the muscle

The pressure that causes ulcers does not have to be very intense. Pressure of less than 25% the pressure of a normal mattress can lead to ulcers. Normally, our skin is protected from being injured by this pressure because we move frequently, even when we sleep.

Although pressure on the skin is the main cause of ulcers, other factors often contribute to the problem.

Decreased Movement: Ulcers are common in people who can’t move because of various reasons such as severe arthritis, obesity, stroke and multiple sclerosis. People who can move with little or no assistance have a lower risk of ulcers because they can shift their weight occasionally.

Decreased Sensation: Ulcers are common in people who have neurological problems that decreased ability to feel or verbally express pain or discomfort. Without these feelings, the person cannot feel the effects of prolonged pressure on the skin.

OTHERS FACTORS THAT CAN CAUSE A PRESSURE OTHERS FACTORS THAT CAN CAUSE A PRESSURE ULCERULCER

Circulatory Problems: People with atherosclerosis, circulatory problems from long term diabetes or localized swelling (edema) may be more likely to develop ulcers. This is because the blood flow in their skin is weak even before pressure is applied to the skin. People with anemia are also at risk because their blood cannot carry enough oxygen to skin cells, even though circulation may be normal.

Poor Nutrition: Studies show that ulcers are more likely to develop in people who don’t get enough protein, vitamins C & E, calcium or zinc.

OTHER FACTORS THAT CAN CAUSE A PRESSURE OTHER FACTORS THAT CAN CAUSE A PRESSURE ULCERULCER

Shearing & Friction: Shearing and friction causes skin to stretch and blood vessels to kink, which can impair blood circulation in the skin. In a person confined to bed, shearing & friction can occur when the person is dragged or slid across the bed sheets. This can also occur when the head of the bed is raised more than 30 degrees. This increases shearing forces over the lower back & tailbone.

Moisture: Wetness from perspiration, urine or feces can make the skin too soft & more likely to be injured by pressure. For this reason, people who can’t control their bladders or bowels (incontinent) are at high risk of developing ulcers.

OTHER FACTORS THAT CAN CAUSE A PRESSURE OTHER FACTORS THAT CAN CAUSE A PRESSURE ULCERULCER

Age: Elderly people, especially those over 85, are more likely to develop ulcers because skin usually becomes thinner with age. Also, as we age, fat tends to shift away from the body surface, where it acts as a cushion, to deeper areas of the body.

OTHER FACTORS THAT CAN CAUSE A PRESSURE OTHER FACTORS THAT CAN CAUSE A PRESSURE ULCERULCER

Symptoms & Stages of Pressure Ulcers

Stage 1 (earliest signs of skin damage) White people or people with pale skin develop a lasting patch of red skin that does not turn white when you press it with your finger. In darker skin, the patch may be more difficult to detect.

Stage 2 The injured skin blisters or develops an open sore or abrasion that does not extend through the full thickness of the skin. There may be a surrounding area of red or purple discoloration, mild swelling & some oozing.

Stage 3 The ulcer becomes a crater that goes below the skin surface

Stage 4 The crater deepens and reaches into a muscle, bone, tendon or joint

Because broken skin is a prime spot for bacteria, ulcers are extremely vulnerable to infection. This is especially true if the sore is contaminated by urine or feces. Signs of infection in an ulcer can include

Pus draining from the sore

A foul smelling odor

Tenderness, heat and increased redness in the surrounding skin

Fever

PRESSURE ULCER PREVENTION

Health care experts believe that at least 50% of ulcers can be prevented by using simple measures to relieve pressure and decrease the skin’s vulnerability to injury. To help prevent ulcers in a person who is confined to a bed or chair, the health care professional should create and follow a plan of care individualized to each person.

The plan may include these strategies:

Relieve pressure on vulnerable areas

Change the person’s position every two hours when in bed and every hour when sitting in a chair. Use pillows to raise

the person’s arms, legs buttocks & hips. Relieve pressure on the back with an egg-crate foam mattress or a water mattress. Two types of beds, air-fluidize beds & low-air-loss beds have

been shown to reduce pressure ulcers by up to two thirds. Use pillows or foam wedges to keep boney prominences such

as knees and ankles from direct contact with each other. Teach chair bound people, who are able, to shift their weight

every 15 minutes.Do not use donut devices!

Reduce Shear & Friction

Avoid dragging the person across the bed sheets. Either lift the person by using a lift sheet or have the person use an overhead trapeze to briefly raise their body. Keep the bed free from crumbs and other particles that can rub and irritate the skin.Do not raise the head of the bed more than 30 degrees, unless they are eating in bed or the doctor tells you otherwise.Use boots & elbow pads to reduce friction on heels and elbows. Elevate heels on pillows if boots are not used.Wash the person gently. Avoid rubbing or scrubbing the skin and make sure they are thoroughly dry.

Inspect the person’s skin at least once each day

Early detection can prevent a Stage I redness from becoming worse.

Minimize irritation from chemicals

Avoid irritating antiseptics, hydrogen peroxide, povidone iodine solution (Betadine) or other harsh chemicals to clean or disinfect the skin.

Encourage the person to eat well

The diet should include enough calories, protein, calcium, zinc and vitamin C & E. If the person cannot eat enough food, offer nutritional supplements.Ask the doctor about ordering vitamin supplements.

Encourage daily exercise

Exercise increases blood flow and speeds healing. In many cases, even bedridden people can do stretches and simple exercises.

Keep the skin clean and dry

Clean the skin with a non-irritating, non-drying soap. Avoid hot water. Dry skin well. Use absorbent pads to draw moisture away from vulnerable areas. If the person is incontinent try to find ways to control or limit the number of incontinent episodes. Toilet the person on a regular basis. Check for wetness several times a day and provide incontinent care. Do not let a person sit or lay in bed wet for long periods of time. Use topical moisture barriers. Lotion skin well to prevent dryness and cracking. Do not massage over boney prominences.

PROGNOSIS

In many cases, the outlook for ulcers is good. Prevention and early detection is the ultimate situation that can be accomplished with care and understanding by all.