01.03 Pressure Ulcers/Pressure injuries (Braden scale)
- Ulcerations in the skin varying in size and depth
- Due to compression of tissue for extended period of time
- Sentinel Event in Acute Care Facilities (hospitals)
- High prevalence in nursing homes and long-term care facilities.
- Stage I
- Skin intact
- Non-blanchable redness
- Stage II
- Partial thickness loss of skin
- Stage III
- Full thickness skin loss
- Extends to dermis and SubQ tissue
- Stage IV
- Full thickness skin loss
- Exposing muscle and bone
- Undermining and tunneling
- Eschar or slough may be present
- Deep Tissue Injury
- Injury to SubQ tissue under intact skin
- Dark purple or brown
- Wound completely covered by eschar or slough – unable visualize
- Cannot determine depth/thickness
- Detailed skin assessment
- On admission
- With two nurses at every shift change
- With head-to-toe assessments
- Check bony prominences with every turn
- If redness present, press with finger to see if it blanches (turns white)
- Measure length, width, and depth
- Measure depth of tunneling or undermining
- Assess color of tissue & color/quality of drainage
- Utilize Braden Scale every shift
- Albumin level to assess nutrition
- Consult Wound Care specialty nurse
- Do NOT massage reddened area
- Intervene as needed for malnutrition and immobility
- Nutrition Consult
- Turn q2h or more often
- Keep skin clean and dry
- Minimize sheets under patient
- Utilize specialty beds or surfaces
- Offload bony prominences with pillow or wedge
- Tissue/Skin Integrity
- Assess all bony prominences and under all devices
- Evidence Based-Practice
- Studies show they can develop in under 2 hours!
- Clinical Judgment
- There is NO excuse for a pressure ulcer
- Document any patient refusal
- Importance of turns
- Reporting any pain or discomfort
- Reposition in bed often
Cornell Note-Taking System Instructions:
- Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences.
- Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Writing questions helps to clarifymeanings, reveal relationships, establish continuity, and strengthenmemory. Also, the writing of questions sets up a perfect stage for exam-studying later.
- Recite: Cover the note-taking column with a sheet of paper. Then, looking at the questions or cue-words in the question and cue column only, say aloud, in your own words, the answers to the questions, facts, or ideas indicated by the cue-words.
- Reflect: Reflect on the material by asking yourself questions, for example: “What’s the significance of these facts? What principle are they based on? How can I apply them? How do they fit in with what I already know? What’s beyond them?
- Review: Spend at least ten minutes every week reviewing all your previous notes. If you do, you’ll retain a great deal for current use, as well as, for the exam.
For more information, visit www.nursing.com/cornell
Okay guys – this lesson is going to talk about Pressure Ulcers. Now, this is a hot-button topic in the hospitals because it is hugely preventable. If your patient does get a pressure ulcer while they’re in the hospital, that’s called a Sentinel Event, which means that the hospital will NOT be reimbursed for that patient’s care. But not only that, we’ve now exposed the patient to a wound and a risk for infection and a prolonged hospital stay. It’s really not okay, so we want you to know what to look for and how to prevent this from happening to your patient.
So you may already know some of this, but let’s review. A Pressure Ulcer, also called a bedsore or a decubitus ulcer, is a wound or ulceration caused by prolonged pressure on tissue. The longer the pressure is there or the more pressure, the more likely for an ulcer to form. Think of it like wearing a path through the woods – the more people the walk along it or the more often, the more the grass dies and it becomes a dirt path. The problem is that evidence shows this can happen with just 2 hours or less of pressure, which is really scary. The most common areas for these to form are over bony prominences and under devices. Think about it, if this is their skin, say on their heel, and the bone is right under it – there’s pressure from the bed or hard surface AND from the bone and so this subQ tissue gets worn down quicker. So the back of the head, elbows, sacrum, hips, and heels are common, I’ll also add the shoulder blades and knees, depending on how the patient is positioned. We also see this under devices a lot – nasal cannulas can cause a pressure ulcer on the nose or the ears, tracheostomies can cause an ulcer on the neck or chest, even a foley catheter pressing against the leg can cause a pressure ulcer.
Now, when it comes to staging, most facilities now require specialty training as a Wound Ostomy Continence Nurse (or WOCN) to be able to officially stage a pressure ulcer – mostly for legal purposes. But we still want y’all to know what you’re looking at. A stage 1 is an area of redness where the skin is intact, but it’s not blanchable. What do I mean by that – well any time you see redness on the skin, you want to press your finger into it. If it turns white, that’s blanching or blanchable – that’s what we want to see. If it’s non-blanchable redness, it can be considered a stage I pressure ulcer. Stage 2 is partial thickness loss of the epidermis only – so it looks like a blister or a superficial wound. Stage 3 is a full thickness loss of skin through the epidermis, dermis, and into the subcutaneous tissue. And Stage 4 is full thickness loss of skin and through into muscle and possibly down to bone. We may see some yellow slough or eschar with both stage 3 and 4. In stage 4 we will also start seeing undermining and tunneling. Undermining is when the edges of the wound roll over and the wound bed is actually larger than what we can see from the outside. Tunneling is when a tunnel forms down into the muscle. You always want to measure the length, width, and depth of these wounds, including the depth of any tunnels or undermining. Again, if your facility has a Wound Care Specialty nurse, we usually consult them for this detailed assessment.
So what do you need to do as the nurse for patients who are at risk? Well first things first, we have to assess our patients’ skin. We will do detailed skin assessments on admission to catch anything the patient may have come in with. We also do a two nurse assessment at shift change so we can put 4 eyes on it, and we look head to toe at their skin with every assessment. We also want to assess a Braden Scale on admission and every shift. This helps us to evaluate their risk based on some common issues like immobility and nutrition, as well as friction and shear, sensation, moisture, etc. But immobility and malnutrition are going to be the two biggest risk factors. The lower their Braden Scale score, the higher the risk. As far as interventions, the MOST important thing we can do is turn these patients every 2 hours or more often. We usually use a turn schedule like Left, Right, Back, Left, Right Back, etc. We just want to reposition them at least every 2 hours. We do NOT massage reddened areas – that only adds more pressure to that area, right? We want to offload bony prominences with pillows or a wedge and we can even use specialty mattresses to decrease the pressure on their skin. We always want to keep the skin clean and dry – especially for incontinent patients – we don’t use briefs in the hospital because it just keeps that moisture there next to their skin. And, of course we can consult specialists like Wound Care and the Nutritionist to help us maximize the patient’s care.
If the patient does develop a pressure ulcer, we’re going to follow the provider or wound care nurse’s orders for daily or twice daily wound care. We could also do wound vac therapy which is negative pressure wound therapy – it promotes healing and helps close up these bigger wounds. Or if there’s a lot of slough or dead tissue, they can actually go to the OR to remove all the dead tissue down to healthy tissue. Most of those patients will also end up with a wound vac.
Now, obviously Tissue/Skin Integrity is a top priority for a patient with a Pressure Ulcer. But I also included clinical judgment. Now, here’s where I’m gonna jump on my soapbox for a second. Guys, there is NO excuse for a pressure ulcer. I’ve seen some MASSIVE stage IV ulcers come from nursing homes that absolutely break my heart because they are a sign of neglect. We know they can develop quickly. We know that offloading bony prominences, using specialty mattresses, and repositioning frequently can prevent them. We want you guys to be a champion for your patients. We want the NRSNG family to be the BEST turners in the whole facility! Turn your patients! Look at their skin. Imagine it’s your grandma in that bed – take care of her and don’t let anything happen to her! Okay? That’s it, soapbox over.
So let’s do a quick recap. Pressure ulcers are wounds that form due to prolonged pressure, usually over a bony prominence or under a device. The more time or more pressure, the higher the risk. Pressure ulcer are staged based on their depth. And of course the worse the wound the harder it is to heal and the more risk there is for infection. Prevention is absolutely key for these patients – there really is no excuse – so assess their skin and turn q2h or more often. Keep your patients clean and dry, fluff them up with pillows to offload those pressure points. And if you need to, consult the wound care nurse or nutritionist to make sure we’re doing what we can to get those wounds healed up.
So those are the most important things you need to know about pressure ulcers, not only to pass nursing school and the NCLEX, but to be a GREAT nurse. We want you guys taking the absolute best care of your patients! Now, go be THAT nurse today. And, as always, happy nursing!