FOCUS ON PRESSURE ULCERS

Transcription

1 SKIN HEALTH AND CURRENT RESEARCH ON PRESSURE ULCERS Prf. dr. Dimitri Beeckman University Centre fr Nursing and Midwifery Ghent University, Belgium Eurpean Pressure Ulcer Advisry Panel Chair f the Scientific Cmmittee FOCUS ON PRESSURE ULCERS Pressure ulcer publicatins/year ( ) N = = 70% /3 studies = preventin FOCUS ON PRESSURE ULCERS

2 FOCUS ON PRESSURE ULCERS Pressure ulcers are internatinally recgnized as adverse utcmes and key clinical indicatrs f the quality f care Nursing sensitive utcme = nursing actins are linked t the presence r absence f pressure ulcers Preventive actins are ne f the mst frequently applied interventins carried ut by nurses Significant impact n nursing resurces (e.g. patient repsitining) and budgets (e.g. high tech redistributing mattresses) CONTENT 1. New insights regarding etilgy 2. Risk screening and traditinal risk assessment tls 3. Diagnsis and implicatins fr preventin, treatment and quality management 4. The at risk patient in a seated pstin: current practice and recmmendatins 5. Mattresses and repsitining: new insights and the limitatins f research CONTENT 1. New insights regarding etilgy 2. Risk screening and traditinal risk assessment tls 3. Diagnsis and implicatins fr preventin, treatment and quality management 4. The at risk patient in a seated pstin: current practice and recmmendatins 5. Mattresses and repsitining: new insights and the limitatins f research 2

3 Pressure Shear Mechanisms leading t tissue destructin Reduced supply f xygen in the tissue (leading t ischemia, including hypxia, glucse depletin, and tissue acidificatin) Muscle defrmatin Tissue destructin Shrt perid f high pressure/shear: tissue destructin Cntinuus lw pressure/shear: tissue destructin New insights? Reperfusin injury 3

4 New insights? New insights? Micrclimate Temperature n the skin surface r tissue temperature Air humidity r the humidity at the skin surface between the bdy and the supprt surface Influence n the susceptibility f the skin/sft tissue fr the effects f pressure, shear r frictin frces New insights? Micrclimate and its elements remain t be fully defined, and its relatinship t pressure ulcer develpment clearly characterised. Evidence t date suggests that extremes f skin Micrclimate temperature and/r humidity/skin misture appear t increase the sensitivity f skin t the damaging effects f pressure, shear stresses and Temperature n the frictin skin surface r tissue temperature Air humidityclark r the M. et humidity al. (2010). at the skin surface between Micrclimate in the cntext. bdy In: and Pressure the ulcer supprt preventin: surface pressure, shear, frictin and micrclimate Influence in cntext n a the cnsensus susceptibility dcument. f Wunds the skin/sft Internatinal. tissue fr the effects f pressure, shear r frictin frces 4

5 New insights? Impaired lymphatic drainage (accumulatin f waste prducts) Tissue defrmatin / direct cell defrmatin The cncepts invlved in understanding pressure, shear, frictin and micrclimate and their synergistic actins in the frmatin f pressure ulcers are cmplex and nt yet fully understd Frictin des nt cause pressure ulcers 5

6 CONTENT 1. New insights regarding etilgy 2. Risk screening and traditinal risk assessment tls 3. Diagnsis and implicatins fr preventin, treatment and quality management 4. The at risk patient in a seated pstin: current practice and recmmendatins 5. Mattresses and repsitining: new insights and the limitatins f research RISK SCREENING Until 2012: 47 (prgnstic) studies Fcus: Braden, Nrtn, Waterlw, Cubbin- Jacksn: Lw very lw quality studies Lw prgnstic ability Better prgnstic ability fr tls which have been studied very limited Examples: Duglas scale, the Fragmment scale, the Sng and Chi scale, The Nrthern Hspital Pressure Ulcer Preventin Plan,... Reasn: limited amunt f studies (n=1) 6

7 RISK SCREENING SENSITIVITY? SPECIFICITY? RISK SCREENING Mix f INDICATORS + FACTORS PREVENTION RISK = DOES THE PATIENT DEVELOP A PRESSURE ULCER? RISK SCREENING 50% chance f a crrect assessment 50% change RISK f making SCREENING a MISTAKE! BUT: als difficulties were bserved when using the clinical experience Skin bersvatin: evidence is available (bt limited) = LISTEN OBSERVE MEASURE AND COMMUNICATE! 7

8 RISK SCREENING Saleh et al. (2009): Des a risk assessment scale (Braden) reduce nscmial pressure ulcers? Pretest- psttest cmparisn (n= 719) Clinical judgment may be as effective as emplying a risk assessment scale t assess the risk f pressure ulcers ULCER Trial (Webster et al. 2011): What is the effectiveness f tw pressure-ulcer screening tls (Waterlw and Ramstadius scale) against clinical judgment in preventing pressure ulcers? Single blind randmised cntrlled trial (n= 1231) N evidence that tw cmmn pressure-ulcer risk-assessment tls are superir t clinical judgment t prevent pressure injury CONTENT 1. New insights regarding etilgy 2. Risk screening and traditinal risk assessment tls 3. Diagnsis and implicatins fr preventin, treatment and quality management 4. The at risk patient in a seated pstin: current practice and recmmendatins 5. Mattresses and repsitining: new insights and the limitatins f research DIAGNOSIS Reliability = 30 70% Classificatin and bservatin Nn- blanchable erythema (NBE) Until 2012: 5 studies Very lw lw quality 1 study f medium quality Cmplex and many mistakes (Cat. II/III) Disagreement between experts: +++ Lw agreement in practice Effect n prevalence / incidence? Majr prblem: Incntinence- Assciated Dermatitis (IAD) 8

9 DIAGNOSIS Beeckman et al. 2009, 2011 Gray & Beeckman 2012 Misture Incntinence Management Urine Faeces Urine/faeces Washing Ureum/amnium ph Bacterial lad Enzym. activity ph Bacterial lad Enzym. activity Ureum/amnium ph Bacterial lad Gentle perineal Chemical irritatin cleansing + Physical irritatin Skin Misturizing permeability Prtecting ph Bacterial grwth Cutaneus infectins Weakened skin + Frictin HEALTHY IAD SKIN CONTENT 1. New insights regarding etilgy 2. Risk screening and traditinal risk assessment tls 3. Diagnsis and implicatins fr preventin, treatment and quality management 4. The at risk patient in a seated pstin: current practice and recmmendatins 5. Mattresses and repsitining: new insights and the limitatins f research 9

10 Adequacy f preventin 2007 (studied in 2002): 9.7 % 2011 (studied in 2008): 10.8 % 2012 (studied in 2009): 6.9 % CAVE: strict study prtcl, significant trends Heel preventin Preventin when seated Prbleem bij zitten? 9.81 x M P = A P = pressure M = weight A = cntact surface PRINCIPLE 1. Increasing cntact surface 2. Pressure redistributin P = 9.81 x M A 10% 20% 60% 100% 80kg 1m mmhg 29.4 mmhg 9.8 mmhg 5.9 mmhg 10

11 SEATED = PRESSURE x5 = 300mmHG Preventin Repsitining Pstures? Frequency? Target? Cushins Research (RCT) Repsitining: 9 RCTs Matressess/cushins: 51 RCTs 11

12 Research (RCT) Quality f the studies (Cchrane cllabratin, RCT fcus) Small samples (lw pwer) Unclear randmisatin Inadequate statistical techniques Blinding (difficult!) Outcmes nt clearly defined Limited fllw- up perid Relevant cntrl grups? Cntrl grups are nt clearly defined N (r limited) fcus n cmfrt, experience, and acceptance Recmmendatins? Mre frequent repsitining is needed in seated psitin cmpared t lying psitin (frequency?) Pressure redistributing cushins are needed fr patients with a reduced mbility and patients at risk fr pressure ulcers develpment Air cushins Alternating cushins? Memry fam cushins 12

13 CONTENT 1. New insights regarding etilgy 2. Risk screening and traditinal risk assessment tls 3. Diagnsis and implicatins fr preventin, treatment and quality management 4. The at risk patient in a seated pstin: current practice and recmmendatins 5. Mattresses and repsitining: new insights and the limitatins f research MATTRESSES AND REPOSITIONING Repsitining Repsitining is better than n repsitining 30 tilt psitin is recmmened Frequency depends n patient/supprt surface in use Mattresses/cushins Use a pressure redistributing mattress/cushin fr patients at risk Dn t frget surgical patients! N evidence that ne mattress utperfrmes n anther mattress (cave lw- air lss) MATTRESSES AND REPOSITIONING Matressess/cushins (Unclear) BOOM f (new) materials/prducts Ratinale is nt always clear New technlgies replace existing technlgies (f which the effectiveness has nt been shwn yet) Fcus n innvatin/develpment and (high cmplex) technlgies limited fcus n research Research can t fllw the speed f innvatin 13

14 MATTRESSES AND REPOSITIONING Recmmendatins Repsitining using the 30 tilted side-lying psitin is recmmended if the individual can tlerate it and her/his medical cnditin allws (back supprted and sacrum free) If sitting in a mre upright psitin in bed is needed, a head-f-bed elevatin f mre than 30 and (a subsequent) sluched psitin (increasing pressure and shear n the sacrum and cccyx) shuld be avided. A Semi-Fwler's psitin (the head f the bed at apprximately 30 and the knees in 30 flexin) shuld be used if the individual is lying in a supine psitin MATTRESSES AND REPOSITIONING Semi-Fwler Prne 30 Lateral 30 CONCLUSION New insights regarding etilgy = new preventin? Risk screening: mre than a scale! Crrect diagnsis = crnerstne f adequate management Fcus n seated patient! Mattresses and respstining: be advised and tailr yur strategy search fr evidence and be creative! 14

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