Evidenced Based Presentation Michelle Scarlett Purpose and Objective of presentation Educate about Pressure Ulcers and its presentation Introduce a case scenario Preventable Measures ID: 364421
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Pressure UlcersEvidenced Based Presentation Michelle ScarlettSlide2
Purpose and Objective of presentation
Educate
about
Pressure Ulcers and it’s presentation
Introduce a case scenario
Preventable
Measures
Current
treatment/intervention
Gaps in reducing frequency
Encouraging the use of current methodsSlide3
Video
on Pressure
Ulcers
http
://
www.youtube.com/watch?v=Eyuguc7KKC4Slide4
Statistics“Pressure ulcers are the 3rd most costly complications following cancer and cardiovascular disease”
Incidence rate 0.4-38 % and prevalence has been reported to be 3.5 -69%
The acceptable incident rate is less than 2%
2/3 of pressure sores occur in the elderly above 70 years of age
In spinal cord injury patients, pressure ulcers occur in 30-85 % of patients in the first month of injury.
Paraplegics and quadriplegics are likely to have multiple ulcers.
The National Pressure Ulcer Advisory Panel reported in 2005 a 68.8% mortality rate in the elderly with stage 3-4 pressure ulcers, because of secondary systemic complications.Slide5
Case scenarioHPI: Patient was a 64 year old white female diagnosed with Alzheimer's. She presented to the hospital on October 4, 2012 from her nursing home, following an obstructed bowel for which she had to have surgery. At the time of her assessment
it was noted that the patient had a stage 3 pressure ulcer of her left buttocks that was progressively turning into a stage 4 ulcer. The patient was about 250
lbs
with impaired mobility of her lower extremities. She was listed to be repositioned every two hours and have her wound flushed with saline solution to assist with healing. However, instead of the ulcer getting better the ulcer got worst. According to the doctor's notes it appears that client wasn’t being repositioned in the nursing home as often as she should have and the conditioned may have continued to get worst if someone didn’t take note to the fact that she hadn’t had a bowel movement in almost a week.Slide6
Pathophysiology
A
pressure ulcer is an irregularly shaped, depressed area that results from necrosis of the epidermis and/or dermis layers of the skin. Prolonged pressure causes inadequate circulation, ischemic ulceration, and tissue breakdown. Muscle tissue seems particularly susceptible to ischemia. Pressure ulcers may occur in any area of the body but occur mostly over bony prominences that can include the occiput, thoracic and lumbar vertebrae, scapula, coccyx, sacrum, greater trochanter, ischial tuberosity, lateral knee, medial and lateral malleolus, metatarsals, and calcaneus.
Some 96% of pressure ulcers develop in the lower part of the body, with the hip and buttock region accounting for almost 70% of all pressure sores.Slide7
Other NamesBed soresDecubitus ulcers
Decubiti
Pressure
soresSlide8Slide9
StagesStage I- Nonblanchable erythema; involves changes in the underlying vessels of the skin; bright red color that does not resolve after 30 min of pressure relief; can be painful and
tender
Stage II-
Partial thickness skin loss of epidermis and dermis; cracks or blisters on skin with erythema and/or
indurations
Stage III-
Full-thickness skin loss of epidermis and dermis; extends down to subcutaneous tissue; appears as a crater or covered by black eschar, wound base usually not painful; indistinct borders; may have sinus tracts or undermining
present.
Stage IV-
Full-thickness
skin loss with extensive destruction of tissue, muscle, bone, and/or supporting structures; appears as a deep crater or is covered by thick eschar; wound base not painful; may have sinus tracts and undermining presentSlide10
Stages 1-4Slide11
Other StagesSuspected deep tissue injury-Area
of localized, discolored intact skin that is purple or maroon-red in color. It may also appear as a blood-filled blister resulting from damage to underlying soft tissue. Preceding skin changes may include skin that is painful, firm, boggy, or that has a different temperature compared to the surrounding
skin Slide12
Other
Stages
Unstageable
-
Full-tissue
thickness loss in which the base of the ulcer is covered by slough or an eschar and, therefore, the true depth of the damage cannot be estimated until these are removed
.Slide13
At Risk PatientsBedridden- limited mobilityIncontinent-moisture
causes maturation of skin
Obese-
more weight bearing on bony prominences
Poor nutrition-
balance of vitamins-C, Zinc and other trace minerals
Mobility is
impaired
-failure to make postural changes
Cognitively
impaired
to state need for change and repositioning
I
“
As a nurse you have to do skin inspections!”Slide14
Nursing DiagnosesIneffective peripheral tissue perfusion related to reduced interrupted blood flow as evidenced by presence of inflamed, necrotic lesions.Slide15
Pressure Ulcers affect and can causeIncreased hospital stayPatients more prone to infections
Loss of self-esteem
Loss of earnings
Amputation
DeathSlide16
Medical and Nursing Interventions and Care Guidelines from current research literature
supporting
international best practice of
Repositioning !!!
Study:
Randomized study on 213 Irish and white patients from 12 long-term hospital settings at risk of developing pressure ulcers. 77% were women, 65 % over 80 years old. 70 % low risk of malnutrition. 77% limited activity. 79 % bed ridden.
Data:
Braden scale-risk assessment, MUST- nutrition, EPAUP-classification
Results:
3 (3%) patients in the experimental group and 13 (11%) in the controlled group developed a pressure ulcer.
Conclusion:
Repositioning older adults at risk of pressure ulcers every three hours at night, using the 30 degree tilt, reduces the incidence of ulcers. The study supports the intervention that repositioning patients is a vital preventive method in avoiding pressure ulcers.
Study based on: http
://www.pressureulcerguidelines.org/therapy/Slide17
30 degree tilt versus 90 degree tiltSlide18
Medical and Nursing Interventions and Care Guidelines from current research literature supportingThe objective of this study was to evaluate the effects of nutrition intervention on nutritional states and healing of pressure ulcers
by standardizing or unified factors including nursing, care and treatment in a multicenter open randomized trial.
Tube-fed
patients with Stage III-IV
pressure
ulcers
were selected. The control group (30 patients) received the same nutrition management as before participating in this trial, whereas the
intervention
group (30 patients) was given calories in the range of Basal Energy Expenditure (BEE) × 1.1 × 1.3 to 1.5. The
intervention
period was 12 weeks. The efficacy and safety were evaluated based on the nutritional states and the sizes of
ulcers
(length × width), and on the incidence of adverse events related to the study, respectively. The calories administered to the control and
intervention
groups were 29.1±4.9 and 37.9±6.5 kcal/kg/day, respectively. Significant interactions between the presence or absence of the
intervention
and the
intervention
period were noted for nutritional states ( p<0.001 for body weight, p<0.05 for
prealbumin
). Similarly, the size of
ulcers
differed significantly between subjects in the
intervention
group and in the control group ( p<0.001). The results suggest that nutrition
intervention
could directly enhance the healing process in
pressure
ulcer
patients
.Slide19
Medical and Nursing Interventions and care guidelines as applied to specific patient
Pressure Ulcer
Classification
- Stage 3
Debridement
- Removing dead
tissues
Assessment, Monitoring & Cleansing
- to prevent urine and feces from entering the wound
Nutrition
for
Healing
- increase protein, vitamin and calorie intake
Pain Assessment &
Management
-medication-
diazepam, baclofen, or
dantrolene
sodium
Support Surfaces for
Treatment
-pillows to relieve pressure on the opposite side and between bony prominences and air birds
Dressings
-Hydrocolloid
dressings
(
DuoDerm
)
Biophysical Agents
Negative Pressure Wound Therapy
Growth Factors & Biological Dressings
Slide20
GapsMore research needs to be completed regarding the right intervals to reposition patients to reduce their risk of pressure ulcers.Studies needs to be focus on the situation of the patient and how to reduce prevalence in their case, as current intervention may not be as effective for all bedridden individuals.Slide21
Pertinent NCLEX style Questions You are caring for a patient and noticed a superficial ulcer on the patient’s buttock that appears as a shallow crater involving the epidermis and the dermis. Which of the following stages would you say best describes this break in skin integrity?Stage I
Stage II
Stage III
Stage IVSlide22
Pertinent NCLEX style Questions
Which
of the following interventions is most appropriate for preventing pressure ulcers in a bedridden elderly client
?
1
.
Slide
instead of lift the client when turning.
2. Turn and reposition the client at least every 8 hours.
3. Apply lotion after bathing the client, and vigorously massage her skin.
4. Post a turning schedule at the client's bedside, and adapt position changes to her situation.Slide23
Don’t forget!!- people who can’t turn themselves need your help!!Slide24
ReferencesAgrawal, K., & Chauhan, N. (2012). Pressure ulcers: Back to the basics. Indian Journal Of Plastic Surgery,
45
(2), 244-254.
Moore
, Z., Cowman, S., & Conroy, R. (2011). A
randomised
controlled clinical trial of repositioning, using the 30° tilt, for the prevention of pressure ulcers.
Journal Of Clinical Nursing
,
20
(17/18), 2633-2644.
doi:10.1111/j.1365-2702.2011.03736.x
Ohura, T.,
Nakajo
, T., Okada, S.,
Omura
, K., & Adachi, K. (2011). Evaluation of effects of nutrition intervention on healing of pressure ulcers and nutritional states (randomized controlled trial).
Wound Repair & Regeneration
,
19
(3), 330-336.
doi:10.1111/j.1524-475X.2011.00691.x
Unbound
Medicine-Disease and Disorders-http://
nursing.unboundmedicine.com/
nursingcentral
/
ub
/view/Diseases-and-Disorders/73697/all/
Pressure_UlcerSlide25
Questions?????