Pressure Ulcer Prevention for OR. Jeanne Knecht RN, CWON Wound/Ostomy Specialist

Transcription

1 Pressure Ulcer Prevention for OR Jeanne Knecht RN, CWON Wound/Ostomy Specialist

2 Benefis Hospital Stats month incident rate 1.90 Benefis Benchmark 3 National Benchmark 5-8 How did we achieve Education Standardized Protocols Pressure Redistribution Mattresses/Chair Cushions/Head Pillows/Stretcher Pads Skin Team nurse from each unit, wound care specialists, dietician

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4 Prevention Because Pain Mortality Financial Burden

5 Pressure Ulcer Incidence Viewed as an indicator of poor quality care Pressure ulcers 2 nd most common claim for wrongful death

6 2007 Pressure Ulcer Definition A pressure ulcer is 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.

7 Normal Capillary Blood Flow Pressure is 32 mm Hg. When greater than 32mm Hg pressure is applied, the capillary blood flow is impeded and tissue damage results.

8 Sites of Pressure Ulcers 65-75% in pelvic area 20-25% on feet

9 Critical Determinants for Pressure Ulcer Development Pressure Shear/Friction Tissue Tolerance to Pressure & Shear

10 Intensity & Duration of Pressure High-intensity pressures for a short period of time can result in tissue damage With low-intensity pressures, it takes a longer period of time to cause tissue damage

11 Factors that Effect Tissue Tolerance to Pressure Nutritional Debilitation Fecal Incontinence Advanced Age Chronic Illness Low Blood Pressure Elevated Body Temperature Smoking

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13 Risk Factors History of Pressure Ulcers Unable or fails to do weight shifts indep. Fecal Incontinence Significant weight loss or gain due to edema Albumin of 2.5 or lower Leaves 25% of tray uneaten

14 Risk Factors (cont.) Diabetes, chronic disease Vascular disease Physical Impairments muscle contractures arthritis

15 OR Risk Factors Age Comorbity (diabetic, pulmonary, cardiac) Time on table > 2 hours Position Type of surgery Hypotensive episodes Decrease H&H

16 OR Risk Factors (cont) Anesthetic Agents - disrupt normal vasodilatation and constriction Pooling of prep solutions - changes ph of skin Straps Length of time in OR Friction Shear

17 OR Risk Factors (cont.) Elevated limbs - reduced perfusion Warming blankets increases metabolic rate = requires greater cellular need for oxygen, nutrients, increased rate of by product removal may not be achievable with anesthesia, immobility, vascular compromise

18 Environmental Risk Factors OR table pads Standard plus gel overlay Viscoelastic foam (memory foam) When comparing against each other patients were 8x more likely to develop a PU on standard plus gel overlay (Scott, Williams, Lummas 2005)

19 The Patient at Risk All OR patients at some level of risk Surgical patients = 42% of all Hosp Acquired Pressure Ulcers Any ulcer that develops within 5 days of an OR visit is considered acquired in the OR Pressure related deep tissue injury under intact skin

20 Determining Risk Braden daily in acute care OR?? Scott triggers Age over 62 Albumen <3.5 ASA score 3 or greater OR over 2 hours

21 Staging of Pressure Ulcers Updated staging 2007, from National Pressure Ulcer Advisory Panel

22 Suspected Deep Tissue Injury Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. May be painful, firm, mushy, boggy, and warmer or cooler that surrounding tissue. Evolution may be rapid even with treatment.

23 Sacrum

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25 Heel

26 Staging

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30 Stage II Pressure Ulcer

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32 Stage II Pressure/Shear Ulcer

33 Stage II Heel Blisters

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35 Stage III Pressure Ulcer

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37 Stage III Full Thickness

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39 Stage IV Pressure Ulcer

40 Stage IV

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43 Unstagable 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. Until enough slough and/or eschar is removed to determine true depth, the ulcer cannot be staged.

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47 Pressure: the major causative factor in pressure ulcer formation

48 Sacral Pressure Ulcer

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51 Ischial Pressure Ulcer

52 Heel Pressure When Supine

53 Pressure Ulcer on Heel

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56 Supine Pressure Points

57 Atypical Pressure Ulcer Sites

58 Atypical Pressure Ulcer Site

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60 Relieve Pressure Standard is every 2 hours?? During procedure?? Heels / Gel pads?? Boots

61 Perform complete skin assessment When positioning on table Before transfer to PAR Document all issues

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63 Friction In OR Transfer to table Position changes Heel sliding during transfer pre-op, intra-op, post-op Tape applied with tension epidermal stripping chemical injury - trapping irritating chemicals Drape removal

64 Shear Shear is caused by the force of gravity pushing down on the body and the resistance between the patient and a surface such as the bed or chair.

65 Shearing Forces Shear causes much of the damage seen with pressure ulcers

66 Shear Forces In OR Reverse Trendelenberg / high lithotomy/ Side shifting Other unusual positions Repositioning during procedure Tape applied with tension

67 Operating Room Interventions: Prevention Identify the Patient at Risk Relieve Pressure use least amount of linen under patient as possible Prevent Shear / Friction Use Pressure Redistribution Surfaces

68 Interventions (cont.) Skin Prep under tape Apply tape opposite to incision Apply tape without tension