2015

Pressure Ulcers
JZ Fall

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imprint of Elsevier Inc.
 Sore spots:

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imprint of Elsevier Inc.
Pressure Ulcer
A localized injury to the skin and/or underlying
tissue due to pressure with or without
shear/friction

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Incidence
Most common sites
Sacrum
Heels

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Inc.
Influencing Factors
Amount of pressure (intensity)
Length of time pressure is exerted (duration)
Ability of tissue to tolerate externally applied
pressure

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Inc.
Contributing Factors
Shearing force: Pressure exerted on the skin when
it adheres to the bed and the skin layers slide in
the direction of body movement
Friction: Two surfaces rubbing against each other
Moisture: Excessive

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Inc.
Risk Factors
Advanced age
Anemia
Contractures
Diabetes mellitus
Elevated body temperature

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Risk Factors
Immobility
Impaired circulation
Incontinence
Low diastolic blood pressure
(<60 mm Hg)
Mental deterioration

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Inc.
Risk Factors
Neurologic disorders
Obesity
Pain
Prolonged surgery
Vascular disease

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Inc.
Clinical Manifestations
Ulcers are graded or staged according to deepest
level of tissue damage:
Stage I (minor) to stage IV (severe)
Slough or eschar may have to be removed for
accurate staging of some ulcers.

Copyright 2014 by Mosby, an imprint of Elsevier

Inc.
Clinical Manifestations
Stage I
Intact skin with non-blanchable redness
Possible indicatorsskin temperature, tissue
consistency, pain
May appear with red, blue, or purple hues in
darker skin tones

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Inc.
Clinical Manifestations
Stage II
Partial-thickness loss of dermis
Shallow open ulcer with red pink wound bed
Presents as an intact or ruptured serum-filled
blister

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Clinical Manifestations
Stage III
Full-thickness skin loss involving damage or
necrosis of subcutaneous tissue that may extend
down to, but not through, underlying fascia
Presents as a deep crater with possible
undermining of adjacent tissue
Depth of ulcer varies by anatomic location.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Clinical Manifestations
Stage IV
Full-thickness loss can extend to muscle, bone, or
supporting structures.
Bone, tendon, or muscle may be visible or palpable.
Undermining and tunneling may also occur.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Clinical Manifestations
Infection signs &
symptoms:
Leukocytosis
Fever
Increased ulcer size, odor, or drainage
Necrotic tissue
Pain

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Complications
Most commonRecurrence
Cellulitis
Chronic infection
Osteomyelitis

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Assessment
Assess pressure ulcer risk on admission and at
periodic intervals based on the patients
condition.

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Inc.
Assessment Tools
Use risk assessment tools such as the Braden
scale for systematic skin inspection.

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Assessment of Patients
with Dark Skin
Look for areas of skin darker (purplish, brownish,
bluish) than surrounding skin.
Use natural or halogen light for accurate
assessment (fluorescent light casts a blue color
that can skew results).

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Assessment of Patients
with Dark Skin
Assess skin temperature using your hand.
An ulceration may feel warm initially, then become
cooler.

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Inc.
Assessment of Patients
with Dark Skin
Touch the skin to feel its consistency.
Boggy or edematous tissue may indicate a stage I
pressure ulcer.
Ask about pain or an itchy sensation.

Copyright 2014 by Mosby, an imprint of Elsevier

Inc.
Planning
Overall goals
No deterioration
Reduce contributing factors
Not develop an infection
Have healing
Have no recurrence

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Prevention
Teaching
Prevention is the best treatment.
Identify risk factors and implement prevention
strategies.

Copyright 2014 by Mosby, an imprint of Elsevier

Inc.
Prevention
Skin Care
Remove excessive moisture.
Avoid massage over bony prominences.
Turn every 1 or 2 hours (with care to avoid
shearing).
Use lift sheets.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Prevention
Skin Care
Position with pillows or elbow and heel protectors.
Use specialty beds.
Cleanse skin if incontinence occurs.
Use pads or briefs that are absorbent.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Prevention
Nutrition
Caloric intake elevated to
30 to 35 cal/kg/day or
1.25 to 1.50 g protein/kg/day
Supplements, enteral, or parenteral feedings may be
necessary.

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Treatment
Document and describe size, stage, location,
exudate, infection, pain, and tissue appearance.
Keep ulcer bed moist.
Cleanse with nontoxic solutions.
Debride.
Use adhesive membrane, ointment, or wound
dressing.
Verify good nutrition.
Teach self-care and signs of breakdown.
Initiate specialty services.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Operative Repair
Skin grafts
Skin flaps
Musculocutaneous flaps
Free flaps

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Inc.