Pressure Ulcers Learning Session 2

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1 Pressure Ulcers Learning Session 2 Gillian O Brien Advanced Nurse Practitioner Tissue Viability Naas General Hospital Pat Mc Cluskey Advanced Nurse Practitioner Wound Care Cork University Hospital Group

2 Learning Outcomes (Part 1) Special Interest Groups: Spinal Cord Injury (SCI), Maternity, Bariatric, Older Adult, Palliative Care & the Critically Ill Patient Risk Factors & Risk Assessment Positioning Surfaces Learning Outcomes (Part 2) MUST SSKIN

3 Spinal Cord Injury (SCI) SCI occurs with damage to the spinal cord that blocks communication between the brain & the body. Higher the SCI, the more dysfunction experienced Sensory, motor and reflex messages are affected SCIs are complete or incomplete & are based on whether any movement and sensation occurs at or below the level of injury SCI affects more men than women & young adults betweentheagesof16and30 Each person s recovery from spinal cord injury is different

4 SCI & Risk of Tissue Injury Risk of tissue injury increases due to immobility, decreased sensation, & altered pathophysiology Risk of PU development impacts individuals with SCI at every stage of care Receiving acute care in a SCI specific facility at the time of injury significantly reduces risk of PU development by the time rehabilitation is introduced If PU develops in acute setting,the length of stay becomes significantly longer, prolonging the recovery period

5 SCI SCI patients face a life-long risk of PU development that impacts their daily living Development of PU s perceived as a perpetual danger Constant tension between living a full life and avoiding situations that increases risk of PU development The On-going awareness and motivation to prevent PU development considered essential Reported barriers in accessing care, services, resources and support (Jackson et al, 2010)

6 Maternity Risks Epidurals Semi recumbent position Enlarged uterus + > pressure on pelvis. Large amount of fluid present Specialist birthing beds with split division Thick fluid resistant mattresses (=less 2 way stretch) Midwives knowledge of Pressure Ulcer Prevention

7 Bariatric Patients The facts: Bariatric is the science of providing healthcare for those who have extreme obesity. Weight & distribution of weight throughout the body are involved in determining a bariatric patient. Body Mass Index (BMI) is the most commonly accepted and consistent language for identifying and defining bariatric patients WHO describe people with a BMI greater than 30 as obese, greater than 40 as severely obese (WHO, 2000).

8 Bariatric Patients contd Obesity has increased dramatically Associated with greater mortality than being underweight Association with PU development is unclear Specific features of tissue damage are identified: maceration, inflammation, tissue necrosis especially in large, deep skin folds Both an increased tissue weight increasing the load on dependent tissues & fragile lymphatic, vascular systems can cause vascular necrosis

9 Bariatric Patients contd Treatment for bariatric & non-bariatric patient is similar but more challenging for the bariatric Cannot always move independently Shear & friction often increased Increased pressure on the bowel & bladder often leads to stress incontinence Respiration can be compromised leading to decreased oxygen in the tissues Limb oedema can lead to blistering & necrosis and ulceration can develop

10 Bariatric Patients BMI >40 = risk assessment with validated scoring tool Important Considerations: Body position Repositioning schedules Skin care Support surfaces Suitable equipment from admission Check for bottoming out of equipment Comfortable girth size Note: Pressure ulcers may develop in unique locations e.g. skin folds or areas where equipment is compressing skin (NPUAP EPUAP 2009)

11 Pressure Ulcers & the Older Adult By the year 2050, it is estimated that older individuals will comprise almost 17% of the global population compared to 7% today ( % in 2003) As we age, there is a deterioration in both the structure of the skin & it s functional ability. Loss of skin integrity may result due to epidermal thinning, flattening of the dermal-epidermal junction, increased cell turnover & collagen production (Intrinsic factors) coupled with exposure to environmental factors such as manual handling /devices/repositioning

12 Pressure Ulcers & the Older Adult NB All the measures associated with risk assessment & SSKIN bundles are equally applicable in the care of the older adult. In addition: Continence attention, barrier products, Atraumatic dressing products, careful handling all important considerations

13 What happens as we get older? Epidermis becomes thinner, cell production slower, cells become larger and irregular Strength and elasticity of the skin affected by collagen changes in the dermis Decrease in fibroblasts that are responsible for protein and collagen synthesis Decrease in the number of epithelial cells and blood vessels Thinning cells do not repair as quickly leading to tissue breakdown and delayed healing

14 Pressure Ulcers & Palliative care End of life can be associated with organ system failure, multiple risk factors can lead to unavoidable pressure ulcers In adults with severe dementia, PU development has been associated with higher mortality rates

15 Palliative Care &Pressure Ulcers Most commonly encountered in specialist palliative care settings. Prevalence ranging from 17%-40% depending on the study. Estimated that approximately 1/3 of palliative care patients experience a pressure ulcer at one time or another Palliative care is focused on prevention & relieving pain & discomfort Implement SKKIN care bundles within the context of comfort & prevention Set realistic goals Patient & family preference must be central to all decision making

16 Pressure Ulcers & Palliative Care Patient assessment to include: Co-morbid health problems (& combinations of) Medications Nutritional status Risk factors, including immobility & incontinence Psychosocial implications Environmental resources Patient/Family wishes/concerns

17 Pressure Ulcers & the Critically Ill Patient Represent the sickest patients in the healthcare system Reported as the highest among hospitalised patients (Black et al 2012) PU development is an additional burden on an already compromised system Risk Factors: Haemodynamic instability, poor tissue perfusion & oxygenation requiring the use of vasoactive medications, coagulopathy & the primary risk factors of their illness such as trauma, emergency surgery, sepsis...

18 Pressure Ulcers Critically ill Patient This cohort of patients have unique additionalneeds in terms of PU prevention especially if their medical condition precludes repositioning

19 Pressure Ulcers & the Critically Ill Patient Low Air Loss Vs Integrated dynamic (powered), Better redistribution of weight & fewer PU s developed (Black et al 2012) Evaluate the need to change the support surface in the patient with spinal instability, oral-pharyngeal airway, haemodynamic instability Haemodynamic instability preventing repositioning includes, active fluid resuscitation to maintain blood pressure, active haemorrhaging, life-threatening arrhythmia

20 Critically Ill Patient contd Repositioning: More frequent, small shifts, regularly monitoring their impact. This will allow some reperfusion (Brindle et al 2013) Resume routine positioning as soon as the patients condition allows Foam cushion under the full length of the calves to elevate the heels or heel suspension devices (effect of vasoactive medications) Observe closely all pressure areas, occiput, ears, shoulders, elbows due to the increased risk Use all repositioning aids available even to make small moves

21 Risk Factors & Risk Assessment Aimed at identifying individuals susceptible to PU development Purpose: To target appropriate interventions and prevent tissue damage Risk Factors include: Activity/Mobility limitations, SCI, Fractured hip, Older adult, long-term care facilities, acutely ill, critical care settings.

22 Key information captured on risk assessment tools Mobility status Pressure ulcer history Urinary continence Recent weight loss Bowel continence Height & weight Feeding assistance needed Skin exam

23 Mechanical boundary Conditions: Magnitude of Load Time & Duration of Load Type of Load (Shear, pressure, friction) Internal Strains/Stresses Risk Factors Susceptibility & Tolerance: Pressure Ulcer? Properties of Tissue Individual Geometry of tissues/bones Individual physiology & repair Individual transport & thermal properties Damage Threshold

24 Tissue Tolerance Refers to the ability of the skin and underlying tissue to tolerate exposure to pressure without adverse effects. Each persons tissue tolerance is different. Another risk factor affecting the development of a pressure ulcer. What

25 Tissue Tolerance contd QUESTION: What happens if a patient is nursed on an active pressure relieving mattress e.g. quattro plus/acute when the risk of PU development is low? Their tissue tolerance would reduce putting them at higher risk for skin breakdown when returning home or to a normal mattress.

26 Risk Assessment Gold Standard = Risk Assessment Tool + Clinical judgement. Despite extensive research no consensus has been reached on which risk factors and what number on the scale (cut-off point) are the best predictors of PU development Risk assessment tools do however encourage systematic evaluation

27 Risk Assessment contd Risk assessments should be completed within 6 hours of admission in the hospital setting and at first assessment in the community If assessed as at risk (WaterlowScore of 15 or > ) then re-assessment is recommended at least weekly. In certain care-settings, daily measurement of risk is recommended e.g. the intensive care setting

28 Repositioning of patients is as important on alternating support surfaces as on static surfaces. Fletcher et al. (2015) Positioning

29 Repositioning Integral component of pressure ulcer prevention and treatment; Sound theoretical rationale Widely recommended and used in practice (lack of robust evaluations of repositioning frequency and position for pressure ulcer prevention mean that great uncertainty remains but it does not mean these interventions are ineffective since all comparisons are grossly underpowered). Current evidence is small in volume and at risk of bias and there is currently no strong evidence of a reduction in pressure ulcers with the 30 tilt compared with the standard 90º position or good evidence of an effect of repositioning frequency.

30 Repositioning contd There is a clear need for high-quality, adequatelypowered trials to assess the effects of position and optimal frequency of repositioning on pressure ulcer incidence. The limited data derived from one economic evaluation means it remains unclear whether repositioning every 3 hours using the 30º iltis less costly in terms of nursing time and more effective than standard care involving repositioning every 6 hours using a 90º tilt (Cochrane 2014, Gillespie et al)

31 Repositioning contd Reposition all patients at risk of or with existing PU s, unless contraindicated Repositioning & Support surfaces, is it still necessary to reposition? Repositioning schedules, are they outdated? Have they a value? Repositioning aids Repositioning Techniques

32 Repositioning contd Determined by the individual s tissue tolerance Assess skin Consider support surface Comfort, dignity & functional ability Avoid friction & shear Avoid positioning on tubes & drains etc Avoid positioning on existing tissue damage +/-30 degree tilt 24 Hour Approach Document

33 30 Degree Tilt Use the 30 degree side-lying position (right side, left side, back side) if the patient can tolerate & medical condition allows Avoid lying postures that increase pressure such as the 90 degree side lying position or the semirecumbent position Limit Head of bed elevation to 30 degrees Prone position: Check all pressure areas, appropriate pressure relieving surfaces

34 Challenges to Repositioning TVN Society UK consensus document identify specific circumstances as being: Haemodynamic or spinal instability that may preclude turning or repositioning Patients who are non concordant with repositioning, refuse assessment and subsequent treatment

35 Challenges to Repositioning contd Patients who are following end-of-life pathways and may not be able to tolerate repositioning as frequently as their skin may require Patients who have not previously been seen by a healthcare professional Patients known to a healthcare professional but an acute/critical event occurs that affects mobility or the ability to reposition (Oussey, 2014)

36 Assessment Do we know the cause and can it be eliminated? Full medical, surgical and social history Physical examination to include: factors that may impede healing e.g., impaired perfusion, impaired sensation, systemic infection Vascular assessment for extremity ulcers Bloods to include Hb, Albumin, Total Proteins, C.R.P. Nutritional Assessment

37 Assessment contd Risk of developing additional ulcers Psychological health, behaviour and cognition Social support systems Functional capacity in regard to positioning, posture Surfaces, Aids, Available care Individual/Family, Knowledge of existing PU, it s development, challenges and management to date

38 Support Surfaces Are defined as specialised devices for pressure redistribution designed for the management of tissue loads, microclimate, and/or other therapeutic functions (National Pressure Ulcer Advisory Panel, 2012) The term Microclimate refers to the temperature and moisture at the skins surface where it comes in contact with a support surface (National Pressure Ulcer Advisory Panel, 2012) Any surface in contact with the skin has the potential to alter the microclimate.

39 Pressure Ulcer prevention devices When selecting equipment or positioning patients, consider: Postural alignment, Distribution of weight, Balance, Stability Pressure ulcer risk reduction (Especially important in the sitting position in bed or chair) Reposition, or where possible teach patient to reposition themselves to redistribute pressure.

40 Surfaces (lying) Support surfaces should be chosen on an individual basis/personal need The extent to which pressure is concentrated over small areas will determine the degree of potential tissue damage Reactive Support; Powered or non-powered has the ability to change its load distribution only in response to an applied load Active Support; Powered producing alternating pressure through mechanical means & has the ability to change its load distribution with or without an applied load

41 Surfaces (lying) contd Constructed with: Foam, Gel, Fluid, Sand, Air Powered: to alter the immersion and envelopment characteristics of the surface to control the microclimate (heating, cooling, controlling moisture) or to redistribute pressure Low Air-Loss: Describes the circulation of air beneath a water-vapour permeable cover to control the humidity at the interface between the individual and the support surface)

42 Surfaces (lying) contd Although total bed rest may create a pressure-free wound environment, it has potential complications: Muscle wasting & joint contracture Loss of bone density Respiratory issues Malnourishment Psychological challenges Social isolation Cost implications ( loss of income) Balancing the physical, social, psychological and financial needs is a challenging dilemma

43 Pressure Ulcer prevention devices Fall into 3 main categories 1. Speciality beds There are many types including Air Fluidised (large volume of air pumped through particles & induce a fluid-like behaviour), Low Air Loss (Deep & Soft selectively interchanged to allow increased airflow over moist skin 2. Mattresses Replacements (Powered, non-powered, Hybrid) 3. Overlays

44 We ve come a long way...

45 Support Surfaces for Treatment of P.U. s Alone they neither prevent or heal pressure ulcers Consider replacing the existing support surface if; the patient cannot be repositioned off the ulcer, has a pressure ulcer on 2 or more turning surfaces, fails to heal or has deterioration of the ulcer despite comprehensive care, is at high risk of developing further ulceration the existing surface bottoms out

46 Support Surfaces for Treatment of P.U. s Before replacing the existing support surface; Evaluate the effectiveness of previous and current prevention and treatment plans. Continue with the repositioning schedule Limit head-of-bed elevation to 30 degrees if patient is on bed rest Use the 30 degree tilt Use transfer aids for repositioning and remove moving and handling equipment after repositioning Increase activity as rapidly as tolerated

47 Choices Grade 1 and Grade 2; High-specification foam (Viscoelastic), Hybrid Grade 2, 3, 4,Unstageableand Deep Tissue Injury: Support surface should provide enhanced pressure redistribution, shear reduction & microclimate control. E.g. Low Air-Loss, Where tissue integrity is deeply compromised and there are multiple sites of ulceration The Air-Fluidised (Sand) Therapy system may be the only appropriate choice

48 Choices contd Selection of support surfaces is complex and cannot be determined solely on the grade of the ulcer Many patients report sleep disturbance from the motor in dynamic surfaces or motion sickness, patient choice is paramount in the decision-making process Heels: Float Other aids include the Heel Suspension Boot, Repose boot, Evolution Patient Positioner

49 Surfaces (Seating) Ideally, ischialulcers should heal in an environment where the ulcers are free of pressure and other mechanical stress Total bed-rest may be prescribed which can potentially lead to muscle wasting, respiratory complications (involve Physiotherapist), social isolation Balancing physical, social and psychological needs against the need for total off-loading is challenging for both the individual and the health care professional Seating cushions must be high-immersion, uniformloading, distribution cushions (Involvement of O.T.is invaluable)

50 Surfaces (Seating) contd The chair should be the right height and width to provide appropriate weight distribution Avoid seating an individual erectly if an ischialulcer exists, use a tilt position Restrict sitting time to 60 minutes three times daily (EPUAP, 2009)

51 Surfaces ( Seating) contd Individualise the selection & periodic re-evaluation of seating support surfaces & associated equipment for posture& pressure redistribution with consideration to: Body size& configuration Effects of posture & deformity on pressure redistribution Mobility& lifestyle needs Individual assessment that includes pressure mapping

52 Seating Surfaces for SCI 1. Evaluation by a seating professional (access to interface pressure mapping& thermography) 2. Consider all seating surfaces (e.g. Commodes, toilets, work/travel seating...) A pressure redistribution cushion must: Provide contour, uniform pressure distribution, high immersion or offloading Promote adequate posture and stability Permit air exchange to minimise temperature and moisture at the buttock interface Provide a stretchable cover that fits loosely on the top cushion surface and is capable of conforming to the body contours No single surface is appropriate for all individuals with SCI

53 Seating Surfaces contd Centre of pressure displacement is significantly lower in individuals with SCI than healthy individuals indicating impaired dynamic sitting stability No difference in centre of pressure displacement between individuals with high or low thoracic SCI Significant pressure displacement during forward leaning and backward leaning positioning for individuals who had a previous PU

54 Seating with existing PU s Tilt / Lean forward when possible & safe (Tilt-in-space, Recline, Standing features in wheelchairs) Pressure relief schedules, frequency and duration of weight shifts Avoid elevating the feet as this can increase the pressure in the sacral area Weigh the risks and benefits of supported sitting versus bed rest against benefits to both physical and emotional health

55 Types of cushions Air Foam Gel

56 Air Air pumped OR alternating air Regular maintenance Unstable base May require assistance with transfers

57 Foam Variety of thicknesses Light No maintenance or adjustment Stable cushions Replace every 6-9 mths Can act as insulation and increase skin temperature

58 Gel Weight distributed evenly Conforms to body shape More stable than air Conduct heat away from use Cleaned easily Heavy and difficult to lift from chair

59 Mattress and cushion. TOGETHER! When pressure relieving mattresses are used, their efficiency is reduced when patients are sitting out of the bed on non-pressure relieving devices (Bliss, 1990)

60 Off-loading Aids

61 Which stage-which device? Stage 1. Static, Overlay Stage 2. Static, Overlay, Alternating Stage 3. Alternating/Low air loss. Stage 4. Alternating/Low air loss/air fluidised + Reposition..Reposition..Reposition

62 Prevention really is the best Intervention Risk Quality Improvement/ Monitor Program Early Care Plan Risk Assess Care Plan Interventions Daily skin check On-going monitoring Re-assessment

63 Thank You

64 PAUSE BuddaMudra are hand gestures to improve physical, spiritual and emotional well being. VitarkaMudra create a constant flow of energy and information to attain clarity of mind. Image Available :

65

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