ann leland, aprn, cnp, dnp - mayo clinic · ann leland, aprn, cnp, dnp instructor, ... mayo school...
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©2015 MFMER | 3543652-2
Pressure ulcers
Wednesday-Saturday, October 19-22, 2016 Sawgrass Marriott Hotel • Ponte Vedra Beach, Florida
Mayo School of Continuous Professional Development
2nd Annual Inpatient Medicine for NPs & Pas:
Hospital Care from Admission to Discharge
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Learning objectives: • Discuss definition of a pressure ulcer • Review pressure ulcer staging • Discuss management/treatment of a pressure
ulcer utilizing a case study
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Pressure ulcer “injury” definition
http://www.npuap.org/documents/PU_Definition_Stages.pdf
• 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.
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Most common locations **Remember devices & equipment **Must be an area affected by pressure
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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
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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 u
lcer is
...
The und
erlyin
g stru
ct...
How lo
ng the u
lcer h
..
All of th
e abo
ve
0% 0%0%0%
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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
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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.
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Deep Tissue Injury • Purple or maroon
localized area of discoloration.
Highlights: 1. May be blister 2. Over pressure point 3. Evolution generally
rapid
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Category/Stage 1 • Intact skin with non-
blanchable erythema. Highlights:
1. Over pressure point 2. Generally associated
with pain and mild induration
3. Indicative of person “at risk”
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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
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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
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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.
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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
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Pre-op dimensions 1x 0.5 Post-op 3 x 5 x 6 cm Ischial Unstageable
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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
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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!
Stage 1
Stage 2
Stage 3
Stage 4
Unstag
eable
No idea
!
17% 17% 17%17%17%17%
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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!
Stage 1
Stage 2
Stage 3
Stage 4
Unstag
eable
No idea
!
17% 17% 17%17%17%17%
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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.
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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
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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
Offloa
d the a
rea
Nutritio
n evalu
ation
Operativ
e deb
ridem
ent
Impr
ove s
epsis
All of th
e abo
ve
None o
f the a
bove
0% 0% 0%0%0%0%
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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
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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
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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
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Questions & Discussion