Ann Leland, APRN, CNP, DNP Instructor, college of surgery

Ann Leland, APRN, CNP, DNP Instructor, college of surgery leland.ann@mayo.edu 2015 MFMER 3543652-1

Pressure ulcers Mayo School of Continuous Professional Development 2nd Annual Inpatient Medicine for NPs & Pas: Hospital Care from Admission to Discharge Wednesday-Saturday, October 19-22, 2016 Sawgrass Marriott Hotel Ponte Vedra Beach, Florida 2015 MFMER 3543652-2

Learning objectives: Discuss definition of a pressure ulcer Review pressure ulcer staging Discuss management/treatment of a pressure ulcer utilizing a case study 2016 MFMER 3543652-3

Pressure ulcer injury 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. http://www.npuap.org/documents/pu_definition_stages.pdf 2016 MFMER 3543652-4

Most common locations **Remember devices & equipment **Must be an area affected by pressure 2016 MFMER 3543652-5

Case study Mr. Pressure-70 yom pt who is wheelchair bound. Presents with sepsis and multiple pressure ulcers. Chronic stage IV left hip pressure ulcer with evidence of osteomyelitis Stage III coccyx pressure ulcer Unstageable left heel pressure ulcer Stage III right heel pressure ulcer Unstageable R lateral 5th metatarsal pressure ulcer with osteomyelitis 2016 MFMER 3543652-6

Pressure ulcer stages indicate: A. How likely the ulcer is to heal B. The underlying structures involved in the ulcer C. How long the ulcer has been present D. All of the above How likely the ulcer is... 0% 0% 0% 0% The underlying struct... How long the ulcer h.. All of the above 2016 MFMER 3543652-7

Pressure ulcer stages indicate: A. How likely the ulcer is to heal B. The underlying structures involved in the ulcer C. How long the ulcer has been present D. All of the above 2016 MFMER 3543652-8

Pressure ulcer staging Staging is used to describe a pressure ulcer including the structures involved. Structures include: epidermis, dermis, subcutaneous fat, tendon, muscle and bone. 2016 MFMER 3543652-9

Deep Tissue Injury Purple or maroon localized area of discoloration. Highlights: 1. May be blister 2. Over pressure point 3. Evolution generally rapid 2016 MFMER 3543652-10

Category/Stage 1 Intact skin with nonblanchable erythema. Highlights: 1. Over pressure point 2. Generally associated with pain and mild induration 3. Indicative of person at risk 2016 MFMER 3543652-11

Category/Stage 2 Partial thickness loss of dermis. Shallow open ulcer. Highlights: 1. Shallow ulcer without slough or bruising 2. Over pressure point 3. Should NOT be used to describe skin tears, tape burns or maceration 2016 MFMER 3543652-12

Category/Stage 3 Full thickness tissue loss, subcutaneous fat may be visible Highlights: 1. Over pressure point 2. No bone, tendon or muscle exposed/palpable 3. May include undermining and tunneling 2016 MFMER 3543652-13

Category/Stage 4 Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar usually present. Highlights: 1. Over pressure point 2. Osteomyelitis probable 3. Often includes undermining & tunneling. 2016 MFMER 3543652-14

Unstageable Full thickness tissue loss in which the base of the ulcer is covered by slough/eschar Highlights: 1. Over pressure point 2. Any eschar on heels should be evaluated by vascular medicine or podiatry 3. Stage cannot be determined until slough removed 2016 MFMER 3543652-15

Pre-op dimensions 1x 0.5 Post-op 3 x 5 x 6 cm Ischial Unstageable 2016 MFMER 3543652-16

Pressure ulcer patient assessment Perform a thorough skin assessment w/in 8 hours of admission, prior to discharge and daily depending on risk. Stage 3 & 4 pressure ulcers are reportable to the department of health. https://www.icsi.org/_asset/6t7kxy/pressureulcer.pdf http://www.health.state.mn.us/patientsafety/ae/pufacts.html 2016 MFMER 3543652-17

Identification is the Key!! What stage is this ulcer?? (Hint: this is patients hip/greater trochanter) A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable F. No idea! 17% 17% 17% 17% 17% 17% Stage 1 Stage 2 Stage 3 Stage 4 Unstageable No idea! 2016 MFMER 3543652-18

Identification is the Key!! What stage is this ulcer?? (Hint: this is patients hip/greater trochanter) A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable F. No idea! 17% 17% 17% 17% 17% 17% Stage 1 Stage 2 Stage 3 Stage 4 Unstageable No idea! 2016 MFMER 3543652-19

Management Surgical debridement is the gold standard for unstageable and infected pressure ulcers. Bedside debridement is indicated in a number of cases: Comfort level of the wound provider Safety of the procedure at the bedside Appropriate analgesia is available Wound is amenable to more superficial debridement (structures easily identified) Enzymatic debridement is also an option. 2016 MFMER 3543652-20

Case study Chronic stage IV left hip pressure ulcer with evidence of osteomyelitis Risk Factors: Wheelchair bound > 30 lb weight loss in prior 10 months Non-communicative (unable to report pain, need to reposition) Chronic kidney disease Severe debility 2016 MFMER 3543652-21

What do you want to do for treatment of this Category/Stage IV ulcer? A. Offload the area B. Nutrition evaluation C. Operative debridement D. Improve sepsis E. All of the above F. None of the above 0% 0% 0% 0% 0% 0% Offload the area Nutrition evaluation Operative debridement Improve sepsis All of the above None of the above 2016 MFMER 3543652-22

What do you want to do for treatment of this Category/Stage IV ulcer? A. Offload the area B. Nutrition evaluation C. Operative debridement D. Improve sepsis E. All of the above F. None of the above 2016 MFMER 3543652-23

Dressing management Choose your dressing based on a number of items: Appropriate for moisture control (absorptive) Appropriate to control bacterial burden Ease of change/replication at home Protective of surrounding skin Comfort 2016 MFMER 3543652-24

Prevention measures Minnesota department of health has implemented the new Turning clock to minimize supine positioning. Accurate risk assessment Skin assessment Timely use of support surfaces Evidence based incontinence skin care 2016 MFMER 3543652-25

Questions & Discussion 2016 MFMER 3543652-26