SKIN BREAKDOWN:PREVENTION,

ASSESSMENT, AND TREATMENT

Joseph Nicholas, MD, MPHAssistant Professor of Medicine

University of Rochester School of Medicine

THE AMERICAN GERIATRICS SOCIETY

Geriatrics Health Professionals.

Leading change. Improving care for older adults.

AGS

OBJECTIVES

• Understand high risk for skin breakdown in older adults and all fracture patients

• Pathogenesis

• Prevention

• Medical implications

• Cost implications

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PRESSURE ULCER

• Decubitus Decumbere — “to lie down” Cubitum — elbow

• Described by Paget in 1873 “The risk of bedsores in the old with a fractured

neck of femur is chiefly in the first week…”

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EPIDEMIOLOGY

• Develop in 5%15% of acute care patients

• Present in 10%35% of nursing home patients

• Develop in up to 20% of geriatric fracture patients (can be as low as 5%)

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HOST FACTORS

• Immobility

• Incontinence

• Malnutrition

• Poor skin perfusion

• Altered sensation (neuropathy)

• Altered sensorium (dementia/delirium)

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EXTERNAL FACTORS

• Pressure

• Shearing

• Friction/tearing

• Moisture

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COMPLICATIONS

• Infection

• Pain

• Psychosocial decline (depression, social isolation, decline in overall health status)

• Cost

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Bauer J, Phillips LG. Plast Reconstr Surg. 2008;121(1 suppl):1-10.

PATHOGENESIS: PRESSURE

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Haleem S et al. Injury. 2008;39(2):219-223.

TIME TO OR IS KEY

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Bass MJ, Phillips LG. Curr Probl Surg. 2007;44(2):101-143.

LOCATION

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'From 'Pressure Ulcers', Joseph E. Grey and Keith G. Harding. British Medical Journal. 2006; Volume 332, Issue 7539: pg.472-475. Copyright 2012 by BMJ Publishing Group. Reprinted with permission.

SHEARING IN BED

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FRICTION

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'From 'Pressure Ulcers', Joseph E. Grey and Keith G. Harding. British Medical Journal. 2006; Volume 332, Issue 7539: pg.472-475. Copyright 2012 by BMJ Publishing Group. Reprinted with permission.

PRESSURE POINTS

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'From 'Pressure Ulcers', Joseph E. Grey and Keith G. Harding. British Medical Journal. 2006; Volume 332, Issue 7539: pg.472-475. Copyright 2012 by BMJ Publishing Group. Reprinted with permission.

PRESSURE ULCER STAGING

STAGE I:NON-BLANCHABLE ERYTHEMA

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STAGE I:NON-BLANCHABLE ERYTHEMA

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STAGE II:SHALLOW, PINK BED, NO SLOUGH

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STAGE II:SHALLOW, PINK BED, NO SLOUGH

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STAGE III: EXPOSED FAT, SUPPORTING STRUCTURES,

FULL-THICKNESS ULCER

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STAGE III: EXPOSED FAT, SUPPORTING STRUCTURES

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STAGE IV:EXPOSED BONE, TENDON, MUSCLE

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STAGE IV:EXPOSED BONE, TENDON, MUSCLE

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UNSTAGEABLE: ESCHAR PRESENT

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DEEP TISSUE INJURY

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PRESSURE ULCERS:APPROACH TO PREVENTION

NURSES SHOULDSCORE PATIENTS DAILY

Braden Scale (most domains are graded 14)• Sensory perception• Moisture• Activity• Mobility• Nutrition• Friction & shear (graded 13)

Score >18 At risk

Score 12 High risk

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PREVENTION

• Get patients out of bed

• Reposition (q2h if high risk, q34h otherwise)

• Inspect/score daily

• Separate bony prominences with pillow

• Float/protect elbows and heels

• Moisturize skin (less friction)

• Keep skin clean and dry

• Manage incontinence/absorb moisture (but no Foley)

• Mattress features

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Houwing RH et al. Clin Nutr. 2003;22(4):401-405.

NUTRITION

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TREATMENT

• Wound care consult

• Clean — saline

• Debridement — autolytic/surgical/chemical Wet-to-dry dressings are non-selective, destroy

granulation tissue, and are to be avoided

• Dressings

• Surgical evaluation for stage 3 and 4

• Antibiotics only if clearly infected (topical vs. systemic)

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OVERVIEW OF DRESSINGS FOR PRESSURE ULCERS (1 of 2)

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Dressing type Description Indication Advantages

Transparent fill Adhesive, semipermeable, polyurethane membrane that allows water to vaporize and cross the barrier

• Management of stage I and II pressure ulcers with light or no exudate

• Maybe be used with hydrogel or hydrocolloid for full-thickness wounds

• Retains moisture• Impermeable to bacteria and other

contaminants• Allows for wound observation• Does not require secondary dressing

(e.g., tape, wrap)

Hydrogel • Water- or glycerin-based amorphous gels, impregnated gauze, or sheet dressings

• Amorphous and impregnated gauze fill the dead space and can be used for deep wounds

Management of stage II, III, and IV pressure ulcers; deep wounds; and wounds with necrosis or slough

• Soothing, reduces pain• Rehydrates wound bed• Facilitates autolytic debridement• Fills dead tissue space• Easy to apply and remove• Can be used in infected wounds or to

pack deep wounds

Alginate Derived from brown seaweed; composed of soft, nonwoven fibers shaped into ropes or pads

May be used as primary dressing for stages III and IV ulcers, wounds with moderate to heavy exudate or tunneling, and infected or noninfected wounds

• Absorbs up to 20 times its weight• Forms a gel within the wound• Conforms to the shape of the wound• Facilitates autolytic debridement• Fills in dead tissue space• Easy to apply and remove

OVERVIEW OF DRESSINGS FOR PRESSURE ULCERS (2 of 2)

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Dressing type Description Indication Advantages

Foam Provides a moist environment and thermal insulation; available as pads, sheets, and pillow dressings

May be used as primary dressing (to provide absorption and insulation) or as secondary dressing (for wounds with packing) for stages II to IV ulcers with variable drainage

• Nonadherent, although some have adherent borders

• Repels contaminants• Easy to apply and remove• Absorbs light to heavy exudate• May be used under compression• Recommended for fragile skin

Hydrocolloid Occlusive or semiocclusive dressings composed of materials such as gelatin and pectin; available in various forms (e.g., wafers, pastes, powders)

• May be used as primary or secondary dressings for stages II to IV ulcers, wounds with slough and necrosis, or wounds with light to moderate exudate

• Some may be used for stage I ulcers

• Impermeable to bacteria and other contaminants

• Facilitates autolytic debridement• Self-adherent, molds well• Allows observation, if transparent• May be used under compression

products (compression stockings, wraps, Unna boot)

Moistened gauze 2 2- or 4 4-inch square of gauze soaked in saline for packing

May be used for stages III and IV ulcers and for deep wounds, especially those with tunneling or undermining

Accessible

CONCLUSIONS

Major weapons against pressure ulcers:

• Time to OR

• Length of stay

• Early mobility

• Relief of pressure (back, buttocks, elbows, heels)

• Clean, dry skin

• Nutrition/hydration

• Skin care consults

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