1. Under Pressure

2. Learner will be able to define what is apressure ulcerhow one is formed Learner will be able to list 5 risk factorsfromIntrinsic and extrinsic risk factors Learner will be able to locate 5 pressurepoints on a bedridden patient Learner will be able to describe 5 measureswhich help prevent pressure ulcers 3. A pressure ulcer is localized injury to the skinand/or underlying tissue, usually over a bonyarea, as a result of pressure, or pressure incombination with shear. 4. Initially, skin is pale due to reduced bloodflow and inadequate oxygen supply. Skin will return to normal color if disruptionof blood flow occurred for a short period.If prolonged pressure, blood cells aggregateand block capillaries. Resultsnon-blanchableerythemastage I. 5. Unstageable Suspected DeepTissue Injury 6. Localized pressure is thought to contribute to pressure ulcerdevelopment by deforming skin and soft tissues, often between abony structure and an external surface (such as a bed or a chair),reducing blood flow and inducing ischemia (decrease oxygensupply) and necrosis (tissue death).Pressure ondeep artery 7. Tissue damage is related to duration and forceof pressure applied. Pressure on the skin has been shown to producegreater reductions in blood flow in a deep arterythan in skin capillaries (smallest blood vessels). Damage is highest in the soft tissues closest tothe bone. C/o burning is one of the earliest indicators ofpressure ulcer development. Patients at highest risk are those who are unableto move or to ask to be moved. 8. Excessive pressure over time: often related todecreased movement.Pressure is defined as the amount of forceapplied perpendicular to a surface per unitarea of that surface.A force applied over a small area will producegreater pressure than the same force appliedover a larger area. 9. Sameamount offorce appliedto both areasofapplicationX Force X ForceArea ofapplication(bodysurface)More pressure Less pressurePressure = Perpendicular forceSurface area 10. Pressure is more evenlydistributed along the foot.Your foot is less likely to hurt!Pressure is greater on heel and atfront sole 11. Pressure RedistributionIncreased Contact Area Pressure ReliefPatientRepositioning: toincrease contact areaeg. No more than a30 degree tiltReactive supportsurfaces: foam, gel orair filled, air fluidizedPatient Repositioning:to remove pressurefrom a particular areaActivesupport: eg.Alternatingpressurewithspecialty bedLifting bodypart: eg. Heelboots, trapeze 12. Shear stresses arise from forcesapplied tangentially to a surface andcauses the object to becomedeformed. 13. Object before application ofexternal forceTangential(parallel) forceApplication of tangential forceproduces deformation and shearstressAngle produced bydeformation = shear strain 14. Shear force or a force created when the skin ofa patient stays in one place as the deep fasciaand skeletal muscle slide down with gravity.This can also cause the pinching off of bloodvessels which may lead to ischemia and tissuenecrosis. Bedridden patients and wheelchairusers in half-sitting position are veryvulnerable for shear wounds. 15. Skin friction is the force caused when twotouching surfaces move in oppositedirections and may result in superficialscuffing or abrasion of the skin. 16. Friction is affected by: Nature of fabrics touching the skin: rough fabricscause resistance to movement force Amount of perpendicular pressure applied: skin Moistness of skin: skin that stays moist is morelikely to be exposed to higher level of friction Surrounding humidity: high levels of humidityincrease skin moisture 17. Assess head-to-toe those at risk from shearstresses/friction: Once a shift More if condition warrants 18. Provide care for those at risk Skin Care: Do not rub reddened areas Apply lotions gently and only use those that do notleave a sticky residue Control skin dampness or maceration (prune lookingskin). Consider using a protective dressing to areas at risk 19. Provide care to those at risk Positioning: Select a suitable position which minimizes the pressureand shear exerted Limit head-of-bed to 30 degrees , unless medicallycontraindicated Use transfer aids to restrict friction and shear If sitting up in bed is necessary, limit period of time,slouched posture, and positions which increase pressureon the sacrum and coccyx (tail bones). 20. Support Surfaces: choose the correct bed 21. Choose devices that protect skin 22. In the context of pressure ulcers,microclimate usually refers to skintemperature and moisture conditions at theskin/support surface contact. 23. Consists of 3 factors: Skin moisture: the presence of fluid on the skinsurface from perspiration, incontinence, orwound/fistula drainage, or the actual moisturecontent of the outer layers of skin. Air movement: can modify temperature andhumidity/skin moisture. Skin surface temperature: increased temperature maybe related to ulcer susceptibility by weakening thestratum corneum (outer layer of skin). 24. Raised body temperature is a risk factor forpressure ulcers development by increasingcell activity and increasing cell oxygen andnutrient needs. If body temperature is raised 1 degreeCelsius, metabolic activity is raised by 10 %. If increases in energy and oxygen cannot bemet, ischemia ( areas with decreased bloodand oxygen supplies) occurs and pressureulcers can develop more quickly. 25. Increased skin temperature may play a role inthe development of pressure ulcers byweakening skins outer layers. Example: skin temperature that is 35 degreesCelsius has only 25% of the mechanicalstrength of skin that has a temperature of 30degrees C. (Surface skin temperature is lowerthan internal body temperature). 26. Ageing skin is lessresilient and more easilydamaged than isyounger skin. Generally thinner Reduced lipid (oil) levelsand water content Has decreased stretch andflexibility. Environmental humidityshould not be below 40%to reduce the likelihood ofdry skin. 27. Excessive moistureon the skin surfaceperspiration, urinaryor fecal incontinence,wound/fistuladrainage or vomit, isthought to contributeto increased risk forthe development ofpressure ulceration. 28. Air flow can: Decrease temperature Can decrease skin moisture Although no hard evidence exists that link air flowwith pressure ulcer prevention, it is known thatexcessively moist skin is more prone to break-down. 29. Repositioning: Gets pressure off areas Allows skin exposed to cool and dry 30. Skin care: Manage incontinence if possible Use barrier creams and sprays Use breathable underpads: only use one underpadas multiple layers defeat beds therapeuticmechanisms. Use lotions for dry skin Keep sheets and clothes dry 31. Patients that cannot move or will not move Patients that are sedated Patients with underlying medical conditionswhich can decrease perfusion (diabetes,hypertension, cardiac conditions whichpredispose to edema, dehydration.) Older patients ( dry skin, circulatory issues) Malnourished patients Bariatric patients 32. Perpendicular force applied to smallarea results in extreme pressure tothat area. High risk for pressureulcer.No pressure applied to bony heel. Perpendicular force is over largerarea which creates much less pressure. 33. Place pillow/cushion long-ways unde. r lower extremity to elevate heel andnot to place pressure on popliteal artery. By placing the pillow long-ways, wecan increase the surface area and have better support as opposed to placingthe pillow horizontally 34. Accurately document food intake All patients should receive a balanced diet ifable to take food by mouth Vegetables, fruits, meats and eggs, grains, dairy Calories and vitamins keeps patients from loosingweight. *Remember, very thin patients are highrisk for pressure ulcers. If patients dont eat adequate amounts,report to nurses. Nurses can contact adietician who can offer supplements. 35. Patients in spica casts need to beturned every 2 hours during the dayand every 6-8 hours during the night.Patients can be log-rolled using the baras the casts are now made of fiberglassinstead of plaster as in the oldtechnique. 36. Patients with spica casts can turn from frontto back and be placed on their sides. Maintain the cast in general alignment withthe chest and shoulder blades to prevent itfrom pressing inward. Prone: keep toes off the mattress by placing asupport under the ankle. Supine: keep heels free of pressure by using arolled towel or small pillow. 37. Patients with hip, pelvic, or leg fractures with good upper body strength cantake the pressure off their sacrums by lifting every 30 minutes. The trapeze isalso useful to lift for a bedpan. Can you see what is wrong in the left pane? 38. Occipital ulcers candevelop quickly due to thelarge occiput (round backof head) and little fatpadding. Using at least 2 caregivers,loosen the c-collar, cleanneck, change pads, andassess skin under the collar.Patients wearing a c-collarstill need to be turned q 2hours and occiputs shouldbe assessed with each turn. 39. Can you explain what a pressure ulcer is andhow one is formed? Can you name risk factors? Can you name measures to prevent pressureulcers? Can you name several pressurepoints? 40. https://www.youtube.com/watch?v=rAMzhcbtHJY