Developed by

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PRESSURE ULCER PROGRAM

• Developed by
• HELEN HOLDER RN, BSN
• Alverno College
• Milwaukee
• holderhc_at_alverno.edu

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• This site was designed with nursing assistants in
  mind!
• Youll learn
• What is a pressure ulcer?
• What is really going on under the skin?
• What part does nutrition play?
• What part do you play to keep them away?

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What should I know after viewing this site?

• Be able to name layers and functions of the
  skin.
• Name those at risk.
• Explain how pressure ulcers are formed.
• Become aware of complications from pressure
  ulcers
• Understand the importance of nutrition.
• Identify the important prevention techniques used
  by CNAs.

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Why Skin?

• One of the largest organs in the body
• Vital for homeostasis
• Protection
• Retards water loss
• Regulates body temperature
• House of sensory nerves
• Contains immune system cells
• Breaks down and uses various chemicals
• Excretes waste

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Layer by Layer

• Skin has three layers
• Epidermis- Outer most layer- 5 distinct layers
• Dermis- Middle layer
• Hypodermis or Subcutaneous Layer

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EPIDERMIS

• Lacks blood vessels
• Cells reproduce grow and shed as dry
• skin
• Contains melanocytes for skin color
• Thickest area of epidermis palms soles

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DERMIS

• Contains blood vessels
• Binds epidermis to underlying tissue
• Contains muscle fibers-arrector pili
• Nerves scattered through out
• Contains hair follicles, sebaceous sweat glands
• Thickness 0.5mm eyelids to 3.0mm soles

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HYPODERMIS

• Subcutaneous
• Loose connective tissue adipose tissue
• Thickness varies
• Holds major vessels in place that supply blood to
  skin
• Insulates body
• No definition from dermal layer

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A function of the skin is?

• Tan nicely
• Excrete waste known as diarrhea
• Regulate the temperature of the body

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NO

• Tanning is nice but not necessary for living.

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NO

• Skin does excrete waste as a function but it
  excretes sweat, not diarrhea which is a function
  of the Gastrointestinal tract

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HOORAY

• The skin regulates the temperature of our bodies.
  To conserve heat, our blood vessels constrict, in
  turn causing shivering that produces heat. To
  cool the body, our blood vessels dilate causing
  blood to carry heat deep in the body to the
  surface, sweat develops, evaporation occurs, the
  body cools.

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Name that layer!

• Name the layer that contains muscle fiber.
• Dermis
• Subcutaneous
• Epidermis

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You got it!

• Arrector pili is the muscle fiber found in the
  dermis that makes your hair stand up when you are
  cold or frightened.

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Try again

• Subcutaneous or hypodermis
• layer that holds major vessels for the skin.

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Better luck next time!

• Epidermis contains no nerve fiber, but if your
  looking for dead skin youve come to the right
  place!

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Genetic Connection

• NONE
• Those at risk people with
• Peripheral vascular disease
• Diabetes
• Paralysis of limbs
• Casts
• Obese/Thin

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Picture This

• Crowded church, packed pews, no cushions, sermon
  that goes on forever and no one can move. Once
  you have positioned yourself you are stuck for
  the duration. How does it feel on your hips and
  tailbone? Were talking real pressure! Now think
  about how someone with no control over their
  movements feels. Perfect set up for pressure
  ulcers!

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How does that ulcer form?

• Resident lying in bed on their back.
• Buttocks, by force of gravity sink into mattress.
  
• Soft tissue presses against the bones that dont
  go anywhere.
• Blood vessels are pinched between bone and weight
  of gravity.
• Blood flow to soft tissue is cut off.
• Cell starvation and death occur
• Pressure ulcer is born.

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FIRST SIGN ISINFLAMMATION

• Redness/non-blanching
• Warmth
• Swelling
• Pain
• Loss of function
• FOR MORE INFORMATION ON INFLAMMATION
• http//www.siumed.edu/dking2/intro/inflam.htm

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http//faculty.alverno.edu/bowneps/inflammation/in
flammindex.htm

Bowne,3/22/2006
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Staging

• 4 levels progression
• No open area
• Deep wound

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Stage I

• Non-blanching redness
• Intact skin
• Precursor to pressure ulcer

• Sorrentino, S.A., Mosbys Textbook for Nursing
  Assistants, 6th Ed., St. Louis Elsevier 2004
  pg. 587.

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Stage II

• Partial thickness skin loss
• Abrasion

• Blister
• Shallow Crater

• Sorrentino, S.A., Mosbys Textbook for Nursing
  Assistants, 6th Ed., St. Louis Elsevier 2004
  pg. 587.

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Stage III

• Full thickness skin loss
• Not through fat layer

• Deep crater
• Damage or Necrosis

• Sorrentino, S.A., Mosbys Textbook for Nursing
  Assistants, 6th Ed., St. Louis Elsevier 2004
  pg. 587.

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Stage IV

• Extensive destruction
• Necrosis

• Muscle/Bone damage
• Tunneling

• Sorrentino, S.A., Mosbys Textbook for Nursing
  Assistants, 6th Ed., St. Louis Elsevier 2004
  pg. 587.

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Necrosis(cell death)
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What is one of the First Signs of Inflammation ?

• Blanching
• Warmth
• Stress

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Blanching

• Inflammation is characterized by redness at the
  site of tissue injury. If you lightly put your
  finger on the reddened area and exert slight
  pressure the area will not whiten or blanch.

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Warmth

• Correct. Warmth is an indicator of inflammation
  due to the increased blood flow to the area.

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Stress

• Try again. Stress may lead to a different type
  of ulcer but doesnt usually lead to a pressure
  ulcer.

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A characteristic of Stage II is ?

• Blister
• Full thickness skin loss
• Tunneling

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Yahoo!

• Blistering is one of the early characteristics of
  the Stage II pressure ulcer.

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No

• Full thickness skin loss happens in the Stage III
  pressure ulcer. The wound will appear as an open
  area and necrosis may be visible.

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Try again

• Tunneling happens during Stage VI. Wounds will
  begin to produce deeper pockets as the tissue is
  eroded away. The pocket may be narrow and
  proceed to another area of tissue, hence the term
  tunnel.

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Factors that lead to Pressure Ulcers

• Malnutrition
• Low protein intake
• Inability to feed self
• Immobility
• Incontinence
• urine/feces on skin

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Warning Signs of Malnutrition

• Sudden/Recent
• weight loss
• Dehydration
• Decrease appetite

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What is Needed?

• Elderly need at least 1200 calories/day
• Protein- for repair regrowth
• Carbohydrates Fats-Tissue
• maintenance energy source
• Vitamins- promote wound healing

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Protein

• Best Sources
• eggs
• milk
• cheese
• yogurt

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Carbohydrates Fats

• Carb sources
• Whole grains
• Cereal
• Rice
• Unsaturated fats
• Olive oil
• Canola oil
• Safflower oil

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Vitamins

• Vitamin C- for collagen formation
• Good Sources Citrus fruit
  strawberries
• Vitamins A E- for tissue repair
• Good Sources orange green vegetables
• Vitamin K- for normal blood clotting
• Good Sources Green leafy vegetables

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Name a Symptom of Malnutrition

• Sudden weight gain
• Consistently decreased appetite
• Excessive thirst

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NO

• Sudden or recent weight loss is a symptom of
  malnutrition

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Youre Right

• An elderly person that is not consistently eating
  at least 1200 calories per day, may be headed
  for the state of malnutrition

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Check again!

• Dehydration is a sign of malnutrition. Excessive
  thirst is a symptom of Diabetes.

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Good Source of Vitamin C?

• Green leafy vegetables
• Liver
• Strawberries

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Not this time

• Vitamin K is found in green leafy vegetables

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Not Liver

• Liver is high in iron and cholesterol but not
  Vitamin C

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Right you are!

• Strawberries are a good source of Vitamin C and
  taste good too!

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PREVENTION

• Best protections against pressure ulcers is
  observation, good skin care,mobility, and good
  nutrition.
• CNAs importance----most direct contact with
  residents

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CNA Role in Nutrition

• Assist at Mealtime
• make it social and take your time feeding
  the resident.
• Give supplements as required.
• Ensure or 2Cal or whatever other supplement
  is ordered.
• Substitute food dislikes for preference.
• Report Record appropriately.

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CNA Role in Immobility

• Reduce pressure
• Turn bed residents every 2 hours. Even a 15
  degree turn helps to relieve pressure on skin
  surface. Use a written turning schedule so that
  others know in which direction the resident is to
  go.

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Positioning

• Position correctly!
• Use pillows to support joints
• Avoid skin touching skin
• Check to make sure no body part is hitting a
  wall or railing
• Remember! Check positioning in the chairs.
  Chairs too small or residents that lean to one
  side may have pressure.

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Keep Resident Moving!!
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Shearing Friction

• Shearing- Skin layers slide in different
  directions
• Friction- causes a rug burn on skin

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Avoid Shearing Friction

• Use lifter sheet to move resident up in bed
• Use assistance of over bed trapeze
• Keep HOB 30 degrees or lower to avoid slipping
  down in bed
• Cup heels elbows during ROM exercises
• Dont drag heels over sheets when using lifts.

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Importance of Skin Care

• Check every 2 hours for incontinence.
• Feces, urine and even soap are abrasive to
  the skin due to a ph imbalance.

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• Clean, Rinse and thoroughly Dry skin after each
  incontinent episode.

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• Moisturize skin with lotion to prevent dry skin.
  Use lotion over bony prominences but do not
  massage reddened areas as it may cause more
  damage to underlying tissue
• Use special barrier creams as ordered

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To avoid a shearing incident the CNA should ..?

• Elevate the HOB 45 degrees
• Use a lifter sheet
• Support the head during ROM

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Too High!

• Never raise the HOB over 30 degrees when a
  resident is confined to bed. Anything over 30
  degrees may cause a shearing incident!

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YEAH!!!

• Use the lifter sheet to move resident more
  easily and saves your back too!

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Not this head!

• When doing ROM you want to protect the heels and
  elbows from dragging across the sheets and
  causing a friction burn.

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How often do you turn a bed ridden resident?

• Every 30 minutes
• Every 4 hours
• Every 2 hours

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Thats Lunch!

• This is the time allotment for your lunch. It is
  important that you take care of yourself and
  dont skip that part of your day!

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TPR

• Temperature, Pulse, and Respirations are usually
  done every 4 hours on residents that may be ill.
  For the bedridden resident, this is far too long
  to lay in one position!

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YES!

• Remember to turn your bedridden resident every 2
  hours to prevent pressure ulcers.

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You never have to worry about residents that sit
in wheelchairs.

• TRUE
• FALSE

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Wrong!

• Residents dont always sit nor are they always
  positioned in the wheelchair correctly. Take a
  minute to make sure there are no areas rubbing or
  resting against hardware on the wheelchair.

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Correct

• You must have checked your resident after you
  positioned them. Obviously there are no areas
  pressed against the hardware of the wheelchair!

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BEST PREVENTION

• Superior Care!
• Keen Observation!
• Prompt Reporting!

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References

• Slide 5- Shier, D., Butler, J., Lewis, R.,
  1996. Holes anatomy physiology, 8th Ed.,
  McGraw-Hill pg. 171.
• Slides 22-25- Sorrentino, S.A., 2004. Mosbys
  Textbook for Nursing Assistants, 6th Ed., St.
  Louis Elsevier pg. 587.
• Slide 20- Bowne, P.,2004. Inflammation Tutorial.
  Retrieved on March 22, 2006 from the World Wide
  Web at http//facultyalverno.edu/bowneps/inflammat
  ion/inflammindex.htm
• Slide 20- King, D., 2006. Southern Iowa
  University. Personal communication.