Pressure ulcers, why and how

1. PRESSURE ULCERS
WHY AND HOW

2. 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. A number of
contributing or confounding factors are also
associated with pressure ulcers; the significance
of these factors is yet to be elucidated”
NPUAP/EPUAP 2009
Decubitus ulcer is NOT synonymous with
pressure ulcer as decubitus implies lying
position or bed confined.

3. MAGNITUDE OF THE PROBLEM
NYSDOH “War on the Sore” 2007
NYS overall nursing home PU prevalence is
9.1% (5% target). Ranks #32 in nation.
1999 study of 42,817 pts in acute care facilities
across U.S. showed PU prevalence of 14.8%,
with nosocomial PU rate of 7.1%
(Amlung, et al; 1999)
1999 analysis reported $2.2 – $3.6 billion dollar
cost associated with1.6 million PU’s annually.
(Beckrich,Aranovich; 1999)

4. PRESSURE ULCERS AND LITIGATION
Perceived by public (and advertised by lawyers) as
poor quality care, ie, PU = Negligence!
1987 OBRA legislation stated “a resident who enters
a facility without a pressure sore does not develop
pressure sores unless the individual’s clinical
condition demonstrates that they were unavoidable”
(Meehan and Hill; 2001)
Avoidability and preventability are key!
Based on initial risk evaluation, and documentation
Most common reason for nursing home lawsuits!

6. PATHOPHYSIOLOGY
Old Hypothesis: Pressure on trapped soft
tissues exceeds mean capillary pressure leading
to ischemia and necrosis.
Now Understood: First evidence of damage in
subcutaneous tissue with epidermis showing no
signs of necrosis until quite late.
Epidermal cells more able to withstand lack of
oxygen than metabolically more active tissues.
Final pathway to PU is hypoxia/ischemia
The skin is an organ; it can fail like other organs!
Witkowski and Parish; 1982

7. THERMODYNAMICS, METABOLISM AND
PRESSURE
Thermodynamic factors in skin/surface interface
As temperature increases, skin becomes more
metabolically active and 02 demands increase
With increased pressure, metabolic demands
not able to be met and skin becomes hypoxic
Hypoxic skin more susceptible to breakdown
Adding friction and shear to already fragile skin
is “perfect storm”

8. THE 4 FORCES
Pressure: Force applied to soft tissue between
hard surface and bony prominence
Friction: Resistance of one body sliding or
rolling over another
Shear: Contiguous tissues sliding relative to
each other parallel to their plane of contact
Strain: Tissue deformation in response to
pressure

9. PRESSURE AND FRICTION
Images Courtesy of Hill-Rom

10. PRESSURE ULCER STAGING
NPUAP – Nat. Pressure Ulcer Advisory Panel
Most recent revision in 2007
Consists of 4 stages plus unstageable and DTI
Many limitations and criticisms but widely
accepted and utilized
Many misconceptions and tends to be subjective
Shea system (1975) most widely used through
the 80’s and similar to NPUAP, I – IV plus closed
NPUAP/EPUAP 2009 – minor modifications

11. 2009 NPUAP – EPUAP GUIDELINES
More information and discussion – doesn’t really
change what we do
Agreement on same 4 stages + DTI and Unstag.
More discussion around:
Holistic patient assessment
Changing assessment = changing treatment
Use of validated tool, ie, PUSH for progress
Assessment and management of malnutrition
Assessment and management of pain

12. STAGE 1
Viewed by NPUAP as sign of risk
“Intact skin with non-blanchable erythema of a
localized area, usually over a bony prominence”
Darkly pigmented skin may simply demonstrate
color change compared to surrounding tissue
May be painful, soft, firm, warmer or cooler than
surrounding area
BEWARE: Do not confuse with deep tissue
injury !

13. STAGE I

15. STAGE I

16. STAGE II
Updated definition to clarify for pressure ulcers
“Partial thickness loss of dermis presenting as a
shallow open ulcer with a red or pink wound bed,
without slough. May also present as an intact or
open/ruptured serum-filled blister”
Blood blisters indicate damage deeper than
dermis and are not stage II
Should not be used to describe skin tears, tape
burns, maceration, dermatitis or denudement

17. STAGE II

18. STAGE II

19. STAGE III
Goal of update was to address variations in
appearances of stage III PU’s
“Full thickness tissue loss. Subcutaneous fat
may be visible but bone, tendon or muscle are
not exposed. Slough may be present but does
not obscure depth of tissue loss. May include
undermining and tunneling”
Depth of stage III varies by anatomic location

20. STAGE III

21. STAGE III

22. STAGE IV
Very little revision for 2007
“Full thickness tissue loss with exposed bone,
tendon or muscle. Slough or eschar may be
present on some parts of the wound bed. Often
include undermining and/or tunneling”
Depth varies according to anatomic location
Exposed bone/tendon usually directly visible
and/or palpable

23. STAGE IV

24. STAGE IV

25. UNSTAGEABLE
Goal of revision to reduce tendency to classify
any ulcer with necrotic tissue as unstageable,
when the depth of the ulcer can be seen.
“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”
If portion of base is visible – it is stageable.
Wounds obscured by appliances, dressings, etc
are NOT unstageable. Move the stuff and look!

26. UNSTAGEABLE

27. UNSTAGEABLE

28. DEEP TISSUE INJURY
Newest PU in updated staging system
“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”
Difficult to detect in dark skinned individuals
Commonly mistaken as stage I
May evolve rapidly in spite of optimal care as
damage already done

29. DEEP TISSUE INJURY

30. DEEP TISSUE INJURY

31. TARGET LOCATIONS
Sacrum and heel – vast majority
(Brown; 2003, Tippett; 2005)
Greater trochanter
Ischial tuberosity
Head
Scapula
Elbow
Iliac Crest
(HTTPS://www.azdhs.gov/als/hcb/files/pressureulcertrn.ppt)

32. PREDICTING RISK
BRADEN SCALE: 6 parameter instrument
1)Sensation
2)Activity
3)Mobility
4)Moisture
5)Friction
6)Nutrition
High Risk: 18 or less in elderly or darkly pigmented skin
16 or less in other adults
(http://www.bradenscale.com)

33. PREDICTING RISK
BRADEN Q SCALE: 7 parameter for Peds
1)Mobility
2)Activity
3)Sensory Perception
4) Moisture
5)Friction-Shear
6)Nutrition
7)Tissue Perfusion and Oxygenation
High Risk: 16 or less (7 for modified Braden Q)
(HTTP://www.nichq.org/pdf/PUBradenQScale.xls)

34. TREATMENT OBJECTIVES
Identification of problem
Debridement of necrotic tissue
Moist wound care without maceration
Control of infection/bioburden
Management of pain
Pressure redistribution/Offloading
Choice of wound care products is individual
preference as long as above objectives met.

35. PRESSURE REDISTRIBUTION

36. GROUP 1 SUPPORT SURFACES
Pressure overlay, foam, air, water and gel pressure
mattresses
Covered if patient meets following criteria:
1)Completely immobile (cannot move w/o assistance) or
2)Limited mobility PLUS numbers 4-7 or
3)Any stage pressure ulcer on trunk or pelvis PLUS 4-7 or
4)Impaired nutritional status
5)Fecal or urinary incontinence
6)Altered sensory perception
7)Compromised circulatory status

37. GROUP II SUPPORT SURFACES
Powered, advanced pressure reducing
mattresses and overlays. Low air loss,
microclimate management, air fluidized therapy
Covered if patient meets following criteria:
1)Multiple stage II ulcers on trunk or pelvis AND
2)Pt has been on comprehensive PU treatment program for past
month including Group I surface and ulcers are same or
worsened or
3)Large or multiple Stage III or IV PU’s on trunk or pelvis OR
4)Recent myocutaneous flap or skin graft for PU on trunk or
pelvis (60 d) AND
5)Pt has been on a group II or III surface immediately prior to
discharge from hospital or SNF (within 30 days)

38. AVAILABLE PROTOCOLS
AHCPR (Agency for Healthcare Policy and Research.
Now known as AHRQ (Agency for Healthcare Research
and Quality).
AHCPR Clinical Practice Guideline #3: Pressure Ulcers
in Adults: Prediction and Prevention.
(AHCPR #92-0047: May 1992)
AHCPR Clinical Practice Guideline #15: Treatment of
pressure Ulcers. (AHCPR #95-0652, Dec 1994).
WOCN Guideline for Prevention and Management of
Pressure Ulcers, 2003
(www.ahrq.gov/news/pcubcat/c_clin.htm#clin014)
(www.wocn.org)

39. COMMON SENSE !
Document complete initial skin evaluation on day of
admission wherever you are (ED, OR, ICU etc)
Complete and document initial risk stratification/score
Develop and follow your protocol
Implement, monitor & document turning and positioning
Monitor, manage and document incontinence
Use good quality moist wound care
Document daily skin sheets on nurses notes
Document wounds completely in terms of size, depth,
drainage, slough/eschar, odor etc
Document wound treatments and changes in treatments
“Common sense is not so common” - Voltaire

40. FUTURE FOCUS AREAS
Nutrition assessment and management
Pain assessment and management
Proper choice of support surfaces
Prevention

41. THANK YOU !