Wounds and Pressure Ulcers

1. Wounds and Pressure Ulcers Karla Malaney, RN,MSN,APRN Clinical Nurse Specialist Division of Plastic Surgery March, 2007 PT LECTURE

2. The Balancing Act in Wound Care

3. The Problem with Pressure Ulcers • Estimate occurs from data on 31 million hospital admissions in l996 • 2.5 million pressure ulcers each year • Of these, 1.7 million are hospital-acquired • 500,000 to 1 million are Stage 2 or worse • Beckrich K, Aronovitch S. 1999. Nursing Economics.

4. Economic Impact of OR Acquired P.U.Bechrich & Aronovitch (1998) • 104 hospitals =1,128 patients • Followed pts. with surgeries over 3 hours for 1-4 days postop • Data suggests • 23% of ulcers which develop in the hospital (375,000 ulcers) start in surgeries > 3 hrs. =$1/2 billion for OR-acquired P.U.

5. Positioning in OR-early signs

6. Positioning in OR—late signs • Heart transplant patient • OR of 5 + hours • Re-admission with concern of wound infection • Not anxious to debride

7. 52yo WM vasculopath on hemodialysis • Admitted for BKA • Resistant to turning • Severe peripheral neuropathy • Hemodialysis 3 times a week, sent to dialysis in tiltback chair

8. Positioning in OR and Postop • Laid on back 8 hours each day • for 3 consecutive days

9. Discharged 6 months later at a loss of $170,000 (cost - payment)

10. Acute Care Costs for Noscomial P.U.Beckrich and Aronovitch (l999) • Total $2.2 to 3.6 billion dollars spent annually on 1.6 million ulcers in U.S. hospitals. • Costs for prevention and treatment of pressure ulcer approach those of cardiovascular disease and cancer • Haalboom JR. (l998) TheLancet

11. Litigation adds to costs • Legal Options • If you or someone you love have suffered from a stage 3 or stage 4 Pressure Ulcer due to the neglect of a caregiver (such as a hospital, nursing home, or assisted living provider), you should immediately contact a competent attorney. The attorney will work with you to determine the legal options that may be available.

12. Litigation • Average liability claim has doubled for nursing homes: • $65,000 in 1992>$150,000 in 2003 (131% increase) • 639% increase in cost per long term bed for liability losses from 1992 to 2003. Wankmiller, N.et al, 2004. • l993 jury awarded $60 million to family for patient who died of complications from P.U. Taylor, l994

13. Etiology and Pathophysiology • Localized areas of cellular necrosis from lack of blood supply • Most frequent over bony prominences exposed to compressing surfaces • Many factors contribute to development

14. Pressure Shear Friction Moisture Temperature Malnutrition Infection Adequacy of circulation These Risk Factors Are:

15. Pressure • Capillary pressure at arteriolar side 32mmHg/12mmHg • Time-pressure relationship

16. Pressure and PositionWhat is wrong with this PICTURE? • High lateral position - 70mmHg pressure at buttocks • Elder skin is more sensitive to pressure

17. Aging Skin

18. Intrinsic Aging—Decline of Skin Functions • Skin becomes thinner, loses elasticity (affects females more because of decreased hormones) • Less well-nourished by blood supply, so drier • Less sweat/sebaceous gland activity • Less cellular turnover

19. Pressure • Sitting position - 300mmHg on ischial tuberosities

20. External surface provides pressure, bony prominence provides counter pressure Causes cone-shaped pressure gradient (tip of the iceberg) Pressure Gradient

21. Shear • Deeper structures slide inside skin envelope • Obstructed, torn, or angulated blood vessels • HOB elevation >30 degrees increases shear

22. Repeated movement of patient in bed or on chair surfaces Lift, don’t drag! Loss of stratum corneum May accelerate onset of ulcer formation Moistness on skin increases effect of friction Friction

23. Immobilization

24. The Burn Patient

25. Turning Can Be Difficult

26. Incontinence

27. Moisture • Leads to maceration, which softens connective tissue • Moist skin is 5 times more likely to ulcerate than dry skin

28. Temperature • Used to treat ulcers with heat lamps • Every 1 degree increase in temperature causes a 10 degree rise in metabolism

29. Malnutrition • Significant relationship between dietary deficiencies and pressure ulcer development • Healing slowed in presence of inadequate protein intake

30. Necrotic tissue fosters bacterial growth Hypoxic environment impedes WBC function Prolonged inflammation impedes neovascularization and collagen synthesis Infection

31. Adequacy of Circulation • Concern for diabetic patients and those with PVD.

32. Psychological Factors • Some evidence that ulcer development tied to perception of self • Depression, disinterest in own care, desire for attention • Chronic emotional stress decreases collagen production

33. More Potential Problems

34. Check the Heel!

35. Waffle Boots--$23 each Foot WAFFLE® Heel Elevator Heel Pressure Relief, Prevents & “Podus” boot we now use.

36. Problems with Solutions Against Pressure

37. Classification System

38. Stage I • Skin redness that is not relieved within 15-30 minutes of relief from pressure

39. Stage I Pressure

40. Stage II • Superficial skin excoriation or blister formation • Epidermal and/or dermal tissue involved

41. Blister= Stage II

42. Stage III • Full-thickness skin loss exposing subcutaneous tissue and producing serosanguineous drainage

43. Full-Thickness Injury

44. Stage IV • Full-thickness skin loss with invasion of fascia, muscle and/or bone

45. Stage IV *Early postop *Late postop

46. Staging Eschar-covered Wounds • Demarcating Pressure Ulcer90y.o. 3 weeks after hip fracture and bedrest

47. Anatomic Location of Pressure Ulcer

48. Left Trochanteric Ulcer

49. Who’s at Risk? • 56 yo female SP CVA, unresponsive to pain, slender • Feeding tube and tolerating diet, indwelling catheter • Foot splints, frequent watery stools

50. The “Right” Foam vs Standard Hospital Mattresses Cochrane Review 5/04 Pts at high risk for P.U., should be given consideration for higher specification foam Merits of low air loss and alternating pressure less clear Cullum et al. 2004.