For Healthcare workers especially nursing students and staffs
1. Mr. Ashish Kamal Reed
( Asst. Nursing Superintendent )
CCM Medical College , Durg , C.G.
2. PURPOSE
The purpose of this self-learning module is to help
guide nurses performing skin assessment and care
according to best practice.
At the end of the module, the nurse will be able to:
•Identify skin assessment protocol
•Identify risk factors for developing pressure ulcers
•Identify at least 3 things to help prevent pressure
ulcers
•Identify the CCM nursing and interdisciplinary team
resources
•Identify ways to manage and treat pressure ulcers
5. NPUAP DEFINITION
(National Pressure Ulcer Advisory Panel)
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.
6. PRESSURE ON VESSELS
Unrelieved pressure
on the skin
squeezes tiny blood
vessels, which
supply the skin with
nutrients and
oxygen. When the
skin is starved for
too long, the tissue
dies, and a pressure
ulcer develops.
9. CLINICAL PRESENTATION
1. Rounded, crater like shapes with regular
edges
2. Over bony prominences, but can take on the
shape of the bone (malleoli vs sacrum)
3. Usually dark regular base that do not bleed
easily
4. 95% over sacrum/coccyx, trochanter, IT,
heel and lateral malleoli
10. STATISTICS
• 70% occur in people over 65
• Most common sites SACRUM AND
HEELS
• Shoulder, heel, and ear were the
favorite sites of newly developed
pressure ulcer.
12. STAGES/PROGRESSION
4 stages depending on amount and time of
ischemia
1. Hyperemia (redness) will occur within 30 minutes of sustained
pressure. If the Pressure is removed the hyperemia will
disappear in approximately 24-36 hours.
2. Depending on a number factors (including general health)
ischemia begins in 2-6 hours of sustained pressure
3. Texture usually feels hard
4. Necrosis begins ~6 hours after sustained pressure.
5. At this stage skin appears blue or greyish and may be
indurated. Recovery at this stage is variable.
6. Finally, if pressure continues, ulceration occurs.
15. 15
STAGE 1: Skin is intact and shows
a non blanchable, localized
redness over a bony prominence.
Redness remains after pressure is
released. Signs and symptoms may
include pain, firm, soft, warm or
cool compared to adjacent tissue. –
EPIDERMIS
STAGE 3: Skin break with deep tissue
involvement down to subcutaneous
layer. Full thickness tissue loss.
Subcutaneous fat may be visible. Bone,
tendon or muscle is not exposed.
Slough may be present but does not
obscure the depth of tissue loss. May
include undermining and tunneling.
STAGE 2: Considered partial thickness
wound. Superficial break in the epidermis or
partial thickness loss of dermis. Presents as
a shiny or dry shallow ulcer without slough
or bruising. This stage should not be used to
describe skin tears, tape burns, perineal
dermatitis, maceration or excoriation.
Bruising indicates suspected deep tissue
injury.
Pressure Ulcer
Staging
STAGE 4: Skin break with deep tissue
involvement down to the bone, tendon, or
muscle. Full thickness tissue loss with
exposed bone, tendon or muscle. Slough or
eschar may be present on some parts of
the wound bed. Often include undermining
and tunneling. Stage 3 and 4 are
considered Full Thickness wounds.
17. 17
Pressure Ulcer Staging
Unstageable: Full thickness tissue
loss in which the base of the ulcer
is covered by slough (yellow, tan,
gray, green or brown) and/or
eschar (tan, brown or black)
in the wound bed.
Suspected Deep Tissue Injury (SDTI):
Skin is purple. Level of tissue
necrosis is suspected to be deep.
18. HEELS
• Second most common site for PrU’s, and
most common site of Deep Tissue Injury.
• Color reflects the degree of DTI:
– Red - hyperemia and ischemia
– Purple – infarction
– Black - necrosis
20. UNAVOIDABLE PRESSURE ULCERS
• According to NPUAP: An individual develops
a pressure ulcer even thought the provider
had evaluated the individual’s clinical
condition and pressure ulcer risk factors’
defined and implemented interventions that
are consistent with individual needs, goals
and recognized standards practice;
monitored and evaluated the impact of the
interventions; and revised the approaches as
appropriate
• “Kennedy Terminal Ulcers”
21. KENNEDY TERMINAL ULCERS
• Ulcers that some people get as they are
dying
• Usually on the sacrum
• Usually pear shaped
• Colors vary
• Irregular borders
• Come on suddenly
• Geriatric phenomenon
22. KENNEDY TERMINAL ULCERS
CONT.
• Often confused for dirt or dried stool in the
beginning, and providers try to wash it off
only to find it is under the skin
• In the beginning it can look like the skin got
scraped off in a bad abrasion
• Progresses rapidly (over a matter of hours)
24. DOCUMENTATION FOR UNAVOIDABLE
END OF LIFE ULCERS
• Complete wound closure may not be realistic goal,
wound may improve but due to progressive or
irreversible underlying medical condition, complete
healing is not expected.
• The wound represents an additional body systems
failure for a person who is progressing towards death
• Patient has been losing weight despite appropriate
nutritional interventions
• A treatment plan emphasizing minimizing pain and
odor related to the dying process
• Repeated hospitalizations or ED visits in past 6
months may indicate overall decline or instability.
26. MUSCLE RESPONSE
1. Muscle damage is more significant than skin damage
because muscle is more sensitive to the effects of
ischemia.
2. Pressure is highest where the muscle or fascia contacts
the bone.
3. The ulcer starts at the bone-soft tissue interface and
extends towards the skin.
4. An ulcer is like an iceberg – has a small visible surface
with a more extensive unknown base.
29. FRICTION
1. Rubbing 2 surfaces against another
2. Friction without pressure causes damage
to only the epidermis and upper dermal
layer (think sheet burn)
30. SHEAR
1. Friction + Gravity = Shear
2. Think elevation of head of bed and person
sliding down in bed or sliding down in reclining
chair
3. Shear stretches and tears vessels, which
reduces the amount of pressure necessary to
cause ischemia and deep tissue injury
4. Shearing can cause undermining and tunneling
*blisters
31. DRYNESS
• Stratum corneum normally has 10-15%
moisture
• When the moisture drops below 10% skin
becomes cracked and fissured, compromising
barrier function and increasing susceptibly to
injury
• Lotions/creams that have urea or lactic acid can
increase kin surface water-binding capacity
• Best to apply immediately after bathing when
skin is damp because the creams trap moisture
under the skin
33. MOISTURE
• 65% Of patients with pressure ulcer are
incontinent.
• If a person is incontinent of feces, the
chances of getting a pressure ulcer increases
by 3X.
• Continued exposure causes maceration –
tissue softening.
• Exposure to sweat or incontinent brief raises
skin pH to 7.1.
• Exposure to urine or stool increases pH to 8+.
34. Moisture continued…
• Acid Mantle of the skin –
–A slightly acidic film of the skin that acts as a
barrier to bacteria, viruses and other
potential contaminants that might penetrate
the skin.
–Skin has a normal pH of 4.5-6.2
–Slightly acidic
–Sweat, urine, stool, some soaps are alkaline
and decrease the acidity of the skin making it
more prone for skin breakdown and
dermatitis.
35. PERINEAL DERMATITIS
• Not to be confused with Pressure Ulcers (but in the
presence of friction, shear or pressure easier to cause
tissue damage)
• Also called incontinence related dermatitis.
• Most common cause of nosocomial diarrhea is C-Diff,
second is candida albicans (yeast)
• Regular use of absorptive pads or briefs raises the pH
of the skin and increases production of perspiration
40. RISK ASSESSMENT
1. Braden Scale –
a. 6 subscales that reflect the degrees of
sensory perception, moisture, activity,
mobility, nutrition, friction and shear.
b. Each subscale is rated on a scale
according to risk and the scores are
totaled
c. Lower scores mean higher risk for
pressure ulcer development
41. POSITIONING
• For bed bound patients, perform full
position change at least every 2 hours.
• Sage Turn and Position Unit
42. 5 PILLOW RULE
1. Pillow 1 under legs to elevate heels (or
Prevelon Heel Protectors)
2. Pillow 2 between ankles if on side
3. Pillow 3 between knees if on side
4. Pillow behind the back (unless you are
using the Turn and position unit)
5. Pillow 5 under the head
43. Do you need to float heels:
Can the patient lift their leg off
the bed by themselves and hold
it a few seconds?
44. RULE OF 25 - 30
1. Head of bed is elevated no more than 30
degrees and the body is placed in a 30
degree laterally included position when
positioned on either side. If the HOB is
raised for eating or watching TV, return to
original 30 asap
2. In the 30 degree lateral inclined position,
hips and shoulders are tilted to 30 degrees
supine position and pillows or foam wedges
are used to keep positioned without
pressure on the sacrum. Never place
directly on trochanter. (Turn and Position
Unit)
45. MORE….
• Use draw sheet and trapeze if possible to
decrease friction
• Do not position, if possible, over area of
break down
• NEVER massage reddened areas (this is
friction and will increase break down)
• Keep in mind heel pads and elbow pads
prevent FRICTION not PRESSURE
47. SEATING
• Instruct patient to self reposition, if able,
every 15 minutes
• If patient is unable to independently
reposition, place on pressure redistributing
cushion and you reposition every hour
• Check for bottoming out
48. PREVENTION OF SHEAR
• Anti-shear mattress
• Lift sheets
• HOB 30 degrees
• Use pillows or wedges
• Use Turn and Position System
49. HAMMOCK EFFECT
• Seat sags in the middle.
• Needs replaced, placing cushion will not
correct
• Thighs roll inward, creating pressure on
trochanters
• Spine slouches, body slides forward
causing pressure on the ITs, and shear
on the buttocks thighs and spine
50. 50
Support Surfaces
• Group 1 static – foam, air, water, gel
• Group 2 Dynamic – alternating pressure,
low air loss, rotational
• Group 3 Air Fluidized (clinitron) – fluidized
beds (not for pts with unstable spine or
pulmonary disease). Good for pts with
multiple PU’s, burns, flaps and grafts
51. MANAGEMENT OF INCONTINENCE
• Bowel and bladder training when
appropriatite
• Loose stools – ask for bulk in diet, dietary
changes, check for c-diff
• Avoid hot water when cleansing
• Do not scrub
• Use skin barriers
• Use open system for management while in
bed and at night
52. TREATMENT
• Remove pressure, friction and sheer
• Stage I PrUs can be healed in one day
• Use of hydrocolloids may be helpful in
increasing the healing rate on stage II, III.
May be used in stage I if semi transparent
• Stage IV or heavily exudating stage II may
need alginate, composites, foams and
transparent films.
• Advanced wound care products (ECM, skin
grafting, wound vacs etc)
53. AHRQ (Agency for Healthcare
Research)RECOMMENDATIONS
• NO foam rings
• No cut outs
• No Donuts
• Why? Pressure and ischemia!
55. LABS CONTINUTED
• Albumin – long term measure of protein status (18-21
days)
• Prealbumin – more current picture of protein status (1-2
days)
• Transferrin – transports iron to bone marrow. Used to
measure visceral protein status. Accurate indicator of
protein stores as it responds more readily than albumin
• Total Lymphocyte count – measures immunity to proteins
(required to elicit immune response necessary to heal)
• Glucose – elevated glucose impairs wound healing by
impairing lymphocyte function and immune response
• Hematocrit – low red blood cells= anemia= decreased
oxygen carrying capacity
• CBC – complete blood count gives overview of general
health status
56. MARKERS OF MALNUTRITION
MILD MODERATE SEVERE
% usual body wt 85-95% 75-84% <75%
*Albumin, g/dL 2.8-3.4 2.1-2.7 <2.1
Pre albumin
mg/dL
10-16 5-9 <5
Transferrin, mg/dL 150-200 100-149 <100
Total lymphocyte
count/mm3
<1500 <1200 <800
57. Transferrin vs Ferritin
• Sick people produce less transferrin, so
the body cannot transport iron to bone
marrow. If you supplement extra iron to
combat anemia, that is converted to
ferritin, which leads to higher infection
risks.
58. Minnesota Starvation Study
• 1944
• Showed that serum albumin was not a
good predictor of nutritional or protein
status
59. UNINTENDED WEIGHT LOSS
1. A 5% loss of weight from the previous month
indicates a significant decline in nutritional
status
2. A 10% loss in 6 months or less indicates a
significant decline in nutritional status
3. Protein energy malnutrition is the most
common form of malnutrition in people with
wounds which results in loss of lean body
mass (LBI)
4. LBI results in catabolism – breakdown of
muscle for energy
***NON HEALING WOUNDS!
60. NUTRITIONAL NEEDS WITH PrU’s
• Calorie needs increase from 1.2-2.0 times the basal energy
expenditure
• Protein needs increase from 1.2-1.5gm/kg body weight. Proteins
are made of amino acids are necessary to generate acute phase
proteins, including collagen and proteogycans
• Fats are important for development of cell membranes
• Fluid requirements are 30 ml/kg body weight or a minimum of 1500
ml/day
• Arginine and Glutamine – amino acids responsible for collagan
formation cannot be metabolized at adequate rate during stress,
therefore must be suplimented
• Vit A – important for deposition of collagin, and fibroblasts
• Vit C – cofactor in collagen formation and fibroblast
• Vit B – necessary to get energy from amino acids
• Copper – required for collagen linking – low = weak scars and
frequent break down
• Iron – important for hemoglobin and transport of oxygen
61. VITAMINS / MINERALS
• Copper, Zinc and Iron all compete for the
same cell receptor.
• If you have weak scar tissue or dehisced
wounds likely too much zinc and not
enough copper which is important for skin
integrity
• Supplements with >30 mg zinc = too much
• New studies do not show any benefit from
supplemental Vit C, plus it can be bad for
kidney stone patients
62. COMPLETE VS INCOMPLETE
PROTEIN
• Complete have all 3 amino acids
• Chicken = complete
• Ground beef and lunch meat = often
incomplete
• Tofu = complete
*protein is most important at breakfast, because
you have all day to absorb it and make it
available for use. If not available during the
day, body will catabolize itself, and then use
protein to replace catabolized tissue.
Constant deficit.
63. ENCOURAGE BLOOD FLOW
• Heal through blood flow
• Exercise: punching, legs kicks, isometrics
etc encourage 10X every hour
• Walking at least 4 times a day if able
• PT/OT
64. ARE ALL ULCERS PRESSURE
ULCERS?
• NO!
• Trauma, skin tears, moisture, arterial,
venous, diabetic.
• These are often confused with Pressure
ulcers.
• Pressure Ulcers are over bony
prominences as a result of pressure.
• Do not stage any other ulcer besides
pressure ulcers
