Pressure Ulcer Prevention Laura E. Edsberg, PhD

Transcription

1 Pressure Ulcer Prevention Laura E. Edsberg, PhD

2 Pressure Ulcer Localized injury to the skin and/or underlying tissue, usually over a bony prominence, resulting from sustained pressure (including pressure associated with shear). National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline

3 Pressure, Friction, and Shear, Oh My What are they? What might cause them?

4 Friction Surfaces sliding with respect to each other Contact force parallel to the skin surface

5 Static Friction Force resisting movement between 2 bodies when they are NOT moving Keeps you from sliding out of bed when head of bed raised

6 Dynamic Friction Force resisting movement between 2 bodies when they are moving Foot rubbing against a shoe Person sliding in bed

7 Shear Role Magnitude Greatest shear load = Greatest injury Goldstein B and Sanders J. Arch Phys Med Rehab 1998.

8 Etiology of Pressure Ulcers Internal response to external load

9 Tissue Tolerance External mechanical load Internal local tissue deformation Deformation threshold Local tissue damage Linder-Ganz, E. J Biomech 2006

10 What Magnitude of Pressure Causes a Pressure Ulcer? Original Curve Pressure Time Kosiak M Reswick JB, Rogers JE

11 What Magnitude of Pressure Causes a Pressure Ulcer? Pressure Failure strength of muscle Proposed pressure vs. time relationship Load that can be tolerated Time Kosiak M Reswick JB, Rogers JE. 1975; Gefen A. Nursing Standard 2009.

12 Duration of Pressure High pressure short duration Type of load Impact Damage not a pressure ulcer Low pressure long duration Shear

13 Etiology of Pressure Ulcer Development Stage 1 / 2 vs. Stage 3 / 4

14 Low Pressure Tissue Damage Mechanism Low pressure threshold Occlusion of blood vessels Ischemia-induced damage

15 Tissue Ischemia Muscle most sensitive Changes appear in muscle tissue prior to skin Vascularity Metabolic demand Daniel RK. Arch Phys Med Rehabil 1981.

16 Tissue Layer Damage Skin over bone 100% ulceration Skin and muscle overlying bone No skin ulceration Muscle fiber necrosis Nola GT. Plast Reconstr Surg 1980.

17 Impact of Ischemia Hypoxia Block removal of waste Lack of nutrients ph changes Reperfusion Following prolonged ischemia* Oxygen free radicals released 17

18 High Pressure Tissue Damage Mechanism Deformation-induced damage

19 Resultant Forces

20 Deformation Mechanism Strains >50% lead to tissue damage within minutes Strong correlation between strains and damage 20

21 Impact of Tissue Deformation Cellular deformations Alter normal cellular homeostasis 21

22 Impact of Deformation Interstitial space Location of transport of nutrients and waste Deformation may alter the space Cell death mechanism Rupture of cytoskeleton Stretching of cytoskeleton Internal pathways Cell Culture Computer Models 22

23 Low vs. High Threshold Damage Mechanism Ischemic loading Changes were reversible Compressive loading Changes irreversible Stekelenburg A. J Appl Physiol 2007.

24 Hypoxia vs. Compression Hypoxia Cell death not significant Compression Immediate cell death Cell death increased with time Gawlitta D. Ann Biomed Eng 2007.

25 Microclimate Temperature, humidity, and airflow at patient/support interface

26 Microclimate Sources of Moisture Perspiration Drainage Incontinence 26

27 Role of Microclimate Dry skin brittle breaks Moist skin Skin weakens Less stiff

28 Impact of Moisture Skin tensile strength decreases Load distribution Moisture increases friction and shear Increased tissue deformation Maceration 28

29 Role of Microclimate - Temperature As temperature rises Increased metabolic demand Ischemia risk Increased moisture Tissue properties 29

30 Impact of Position on Microclimate Skin temperature Alterations in superficial blood flow Changes in positioning Contact with skin Sleep positions 30

31 Blood Flow Changes Blood flow over bony prominences Most impacted in superficial skin 30 lateral position over trochanter Decreased significantly compared to supine Expected 90 lateral position to have largest decrease Greater interface pressure Källman U. J Adv Nursing

32 Superficial Changes to Blood Flow Significant differences between subjects in both depth and location Same patients did not have decrease in all positions Blood flow response to any situation is unique Not easy to predict Källman U. J Adv Nursing

33 Impact of Age on Microclimate Elderly reduced ability to dissipate heat Blood vessel changes Increased temperature and skin moisture 33

34 Role of Temperature in Reactive Hyperemia Pressure and temperature predictors of extent of reactive hyperemia Upper 1-3mm of tissue in healthy volunteers Index of ischemia, laser Doppler flowmetry Lachenbruch C. OWM, February

35 Role of Temperature in Reactive Hyperemia At higher temperatures (32-36C) reactive hyperemia increased significantly Greater increase with higher pressure and shear Lachenbruch C. OWM, February

36 Role of Microclimate - Temperature Temperature increases Increase metabolic demand Ischemia risk Increase moisture 36

37 Role of Microclimate in Etiology Significant Details emerging Relationship to loading 37

38 Pressure Ulcer Development Load Magnitude, Type of load Pressure, shear Duration

39 Pressure Ulcer Development Location Tissues present Muscle Anatomical blood supply Morphology of individual Individual physiology

40 Pressure Ulcer Development Tissue response Transport properties Perfusion and Oxygenation Thermal properties SCI Microclimate

41 Strategies to Prevent and Treat Pressure Ulcers 2014 International Guideline

42 Strategies to Alter Microclimate Patient skin interface Support surface Linen 42

43 Support Surface Selection Additional features to consider Ability to control moisture Ability to control temperature Strength of evidence (SOE) Strength of recommendation (SOR) SOE = C, SOR = 43

44 Specialized Support Surfaces Low air loss Aid management by allowing air to flow through surface No evidence for optimal levels of skin temperature and moisture Clinical judgment 44

45 Support Surface Cover Selection Moisture and temperature In contact with the skin Selection to control microclimate Vapor permeable surface cover Draw moisture and heat away from interface SOE = C, SOR = 45

46 Strategies to Control Microclimate Do not apply heat directly on skin Water bottles Heating pads Built-in bed warmers Increase metabolic rate Induce sweating Decrease tissue tolerance SOE = C, SOR = 46

47 Strategies to Control Microclimate Fabrics and textiles 47

48 Current Bedding Hospital, nursing home, hotel, or at home Usually sleeping on poly/cotton or 100% cotton bedding Health care linens have changed very little in the last half century Typically cotton fabrics and have no special properties 48

49 Can Linens Impact Patient Microclimate? Basis of modern sports apparel 49

50 Synthetic Silk-Like Fabrics Rather than cotton or cotton-blend Reduced shear and friction Friction for cotton bed linens increases significantly when wet. SOE = B, SOR = 50

51 Synthetic Silk-Like Fabrics Smooth not slippery 51

52 Moisture Control Silk-like fabrics maximize moisture wicking and drying of bed linens Water loss from fabric is facilitated through rapid wicking and evaporation 52

53 Temperature Control Wicking and evaporation Removes heat from the body Reduces perspiration 53

54 Impact on Pressure Ulcers Reduced incidence of hospital acquired pressure ulcers Reduced deterioration of pressure ulcers 4 Studies RCT, non-blinded CT, Cohort, retrospective record analysis SOE = B, SOR = 54

55 Prophylactic Dressings Apply to bony prominences for prevention of pressure ulcers Reduction of friction and shear at anatomically at risk areas SOE = B, SOR = 55

56 Characteristics of Dressings Material Polyurethane foam Film Hydrocolloid Dressing layers 56

57 Characteristics of Dressings Adhesive types Silicone Elastic Size of dressing 57

58 Factors to Consider When Selecting Ease of removal/application Ability to assess skin Location where it will be applied Damaged, displaced Correct size SOE = C, SOR = 58

59 Impact on Microclimate Trap moisture Humidity Dressing transpiration properties Increase temperature at skin surface SOE = C, SOR = 59

60 When to Use Sacral Dressing Is the patient expected to have 1 or more of the following? A surgical procedure lasting longer than 3 hours Inpatient or outpatient surgical procedures More than 2 trips to the OR Multiple procedures (ex. CT, MRI, IR) Has a diagnosis of: Shock, SIRS, Hypovolemia, Trauma, Multisystem Organ Failure L McNichol, MSN, RN, GNP, CWOCN 60

61 Patient has 3 or More of the Following: (Both surgical patients and non-surgical patients) Weeping Edema/Anasarca Traction Anticoagulation Therapy Morbid Obesity Malnutrition (Albumin <2.5; Prealbumin <20) NPO > 3 days Age >65 years old Diabetes Mellitus Orders for Bed-Rest Liver Failure L McNichol, MSN, RN, GNP, CWOCN Sedation/Paralytics > 48 hours Mechanical Ventilation >48 hours Quadriplegia or Spinal Cord Injury Restraints Past History of Sacral Pressure Ulcer CVVHD Urinary or fecal incontinence not controlled by a catheter, pouch, or bowel management system 61

62 With Dressing Use, Continue To Use all other preventative measures Assess skin at each dressing change or at least daily and confirm if should continue use Borders easy to lift and assess SOE = C, SOR = 62

63 Dressing Use Replace dressing if it becomes damaged, loosened, or excessively moist SOE = C, SOR = 63

64 Electrical Stimulation of Muscles Use at anatomical locations at risk in SCI Patients Reduced risk of pressure ulcer development Based on indirect evidence and expert opinion SOE = C, SOR = 64

65 Electrical Stimulation for Muscles Intermittent tetanic muscle contractions May decrease muscle atrophy Improve blood flow Tissue oxygenation Increase muscle mass Redistribute loading on tissues Change stiffness of tissues 65

66 Details of the Protocols Gluteal and hamstring muscles SCI Seated Special shorts with integrated electrodes Biphasic pulsed current 50 pps induce tetanic contraction Amplitude mA 66

67 Findings of the research Peak and mean pressure under tubers measured throughout Peak pressure decreased significantly Pressure gradient decreased during 3 hour stim period Improved pressure redistribution Janssen T,

68 E-Stim Protocol 2 sessions 1 hour each 3 minutes stimulation/17 minutes rest 1 second on/4 seconds off for 3 minutes 1 st hour gluteal muscles stimulated 2 nd hour gluteal and hamstring stimulated Smit C,

69 Findings of the research Significant interface pressure relief Both gluteal and gluteal/hamstring Gluteal/hamstring significantly more mean pressure relief than gluteal alone Pressure gradient decreased only after gluteal/hamstring 69

70 Use of Electrical Stimulation Temporary decrease in peak sitting pressure under tuber area Improved pressure redistribution Difference between mean pressure under tuber areas and surrounding areas Gradient Indication of shear forces? 70

71 Exciting New Prevention Strategies Support surfaces Role in microclimate management Features for pressure redistribution Prophylactic dressings Implement a decision tree for utilization 71

72 Emerging Prevention Strategies Linens and textiles Involve decision makers Housekeeping Electrical stimulation Physical therapy Integrate into daily routine 72

73 Thank You

74 QUESTIONS?