The Pressure Sore Case: a Medical Perspective

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Marqueꢀe Elder's Advisor

Volume 2

Issue 2 Fall

Article 7

e Pressure Sore Case: A Medical Perspective

Jeﬀrey M. Levine

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Levine, Jeﬀrey M. (2000) "e Pressure Sore Case: A Medical Perspective," Marqueꢀe Elder's Advisor: Vol. 2: Iss. 2, Article 7.

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A Brief History of Pressure Ulcer Measurement in England: the Last 20 Years

EDITORIAL A brief history of pressure ulcer measurement in England: the last 20 years ressure ulcers (PU) have long been Measuring pressure ulcers: recognised as a challenge to healthcare, are prevalence and incidence a cause of significant pain and distress for During this time, the most reported forms of Ppatients and are costly for healthcare providers measurement have been prevalence and incidence. in term of finances and use of human resource Prevalence is the proportion of a population (Guest et al, 2020). who have a specific characteristic in a given This paper, the first in a series of three, describes time period. Therefore, the prevalence of PUs is the predominant methods that have been used to the proportion of a defined patient population JACQUI FLETCHER OBE capture the prevalence of PUs in England over the with pressure damage during a specified time Clinical Lead Pressure Ulcer last 20 years. The second paper will describe the period. Incidence is the number of specified new Workstream National Wound proposed system for national PU measurement events, during a specified period in a specified Care Strategy Clinical Editor, Wounds UK in England and the third paper will outline population. Therefore, the incidence of pressure proposals for implementing this system to drive damage is the number of people in a defined quality improvement. patient population who develop a new PU during a specified time period. BACKGROUND Prevalence of pressure damage is a good Measurement of the occurrence of PUs (also indicator of the overall burden and clinical known as pressure sores, decubitus ulcers, workload related to pressure damage but does pressure injury and bed sores) has been a part of not identify when and where the PU occurred, nursing activity for many years.
Wound Classification

Wound Classification Presented by Dr. Karen Zulkowski, D.N.S., RN Montana State University Welcome! Thank you for joining this webinar about how to assess and measure a wound. 2 A Little About Myself… • Associate professor at Montana State University • Executive editor of the Journal of the World Council of Enterstomal Therapists (JWCET) and WCET International Ostomy Guidelines (2014) • Editorial board member of Ostomy Wound Management and Advances in Skin and Wound Care • Legal consultant • Former NPUAP board member 3 Today We Will Talk About • How to assess a wound • How to measure a wound Please make a note of your questions. Your Quality Improvement (QI) Specialists will follow up with you after this webinar to address them. 4 Assessing and Measuring Wounds • You completed a skin assessment and found a wound. • Now you need to determine what type of wound you found. • If it is a pressure ulcer, you need to determine the stage. 5 Assessing and Measuring Wounds This is important because— • Each type of wound has a different etiology. • Treatment may be very different. However— • Not all wounds are clear cut. • The cause may be multifactoral. 6 Types of Wounds • Vascular (arterial, venous, and mixed) • Neuropathic (diabetic) • Moisture-associated dermatitis • Skin tear • Pressure ulcer 7 Mixed Etiologies Many wounds have mixed etiologies. • There may be both venous and arterial insufficiency. • There may be diabetes and pressure characteristics. 8 Moisture-Associated Skin Damage • Also called perineal dermatitis, diaper rash, incontinence-associated dermatitis (often confused with pressure ulcers) • An inflammation of the skin in the perineal area, on and between the buttocks, into the skin folds, and down the inner thighs • Scaling of the skin with papule and vesicle formation: – These may open, with “weeping” of the skin, which exacerbates skin damage.
The Role of Pressure Ulcers in the Fight Against Antimicrobial Resistance

The role of pressure ulcer prevention in the fight against antimicrobial resistance Every year over 25,000 patients die in the EU alone as a result of infections caused by antibiotic- resistant bacteria. Globally the number of deaths due to antimicrobial resistance (AMR) was estimated to be 700,0001 in 2014 and that number has been calculated to rise to at least 10 million by 2050. The continuing emergence of AMR has become a recurring topic in the international health agenda as the increasingly serious threat to cross-border public health is recognised. From WHO to OECD, international bodies are constantly monitoring, reporting and formulating strategies to contain AMR. AMR is defined by WHO as the ability of microorganisms to survive antimicrobial treatments; consequently, prophylactic and therapeutic regimens are ineffective in controlling infections caused by resistant bacteria, fungi, parasites and viruses.2 The situation has deteriorated dramatically in the past decade with AMR reaching levels of 80% in some countries.3 How has this happened? Whereas greater investment and skill in reporting of AMR may be one reason, an important consideration is that AMR is a natural and inevitable process which is aggravated by the inappropriate use of antimicrobial agents. Healthcare authorities have been aware of the consequences of overuse of antibiotics in animal and human health, yet relatively few actions have been implemented to slow the process down.4 The good news is that the EU has made a significant step forward to gain a global lead in the fight against AMR. In June 2017 the Commission adopted the ambitious EU One Health Action Plan against AMR5 (as requested by the Member States in the Council Conclusions of 17 June 2016).
Clinical Case of the Month Pressure Ulcer Treatment

Spinal Cord (1997) 35, 641 ± 646 1997 International Medical Society of Paraplegia All rights reserved 1362 ± 4393/97 $12.00 Clinical Case of the Month Pressure ulcer treatment F Biering-Sùrensen1, JL Sùrensen2, TEP Barros3, AA Monteiro3, I Nuseibeh4, SM Shenaq5 and K Shibasaki6 1Centre for Spinal Cord Injured, the Neuroscience Centre, and 2Department of Plastic Surgery, Rigshospitalet, Copenhagen University Hospital, Denmark; 3Spinal Injury Unit, Department of Orthopaedics, University of Sao Paulo, Brazil; 4National Spinal Injuries Centre, Stoke Mandeville, England; 5Department of Surgery, Baylor College of Medicine, The Methodist Hospital, Houston, Texas, USA; 6Spinal Cord Division, Department of Orthopedic Surgery, National Murayama Hospital, Japan Keywords: spinal cord injury; paraplegia; pressure ulcer; management; treatment; surgery Introduction The complicated case story below was presented to and found. Over the sacrum there was an ulcer measuring discussed by senior colleagues from Brazil, England, 2.561.5 cm with bone at the base. The plastic surgeon Japan and USA. None of the the responders knew that concluded, not least because of the patient's mental the patient had sustained his injury in 1981, and the habitus, not to operate, but to try conservative initial report stopped at the New Year 1986/87. A treatment. X-ray gave no indication of osteitis. Three review of the patient's medical history for the following weeks later the left trochanteric ulcer measured 3.5 cm years up to date is presented. Finally a short discussion in diameter and 3.5 cm in depth with necrosis and an of the possibilities of treatment is given. iliotibial tract at the base.
Pressure Ulcers By: Esther Hattler BS,RN,WCC

Pressure Ulcers By: Esther Hattler BS,RN,WCC Staging Objectives The attendee will be able to list the 6 stages of pressure ulcers. Stage I Definition Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching. Its color may differ from surrounding area. Description Stage I The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk). Pictures stage I Stage II Definition Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, WITHOUT slough. May also present as an intact or open ruptured serum filled blister. Description stage II Presents as a shiny or dry shallow ulcer WITHOUT slough or bruising. The stage II should NOT be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Pictures stage II Stage II Stage III Definition Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Description stage III The depth of a a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers.
Pressure Injuries Caused by Medical Devices and Other Objects: a Clinical Update

WOUND WISE 1.5 HOURS CE Continuing Education A series on wound care in collaboration with the World Council of Enterostomal Therapists Pressure Injuries Caused by Medical Devices and Other Objects: A Clinical Update A review of practical resources, including mnemonics, to aid in prevention and identification. ABSTRACT: At the April 2016 National Pressure Ulcer Advisory Panel (NPUAP) consensus conference, termi- nology and staging definitions were updated and two definitions were revised to describe pressure injuries (PIs) caused by medical devices or other items on the skin or mucosa. Here, the authors discuss the etiology and prevention of PIs resulting from medical and other devices, the frequency of such injuries, and the bodily sites at which they most often occur. They provide an overview of the current NPUAP guideline, highlight im- portant risk factors, and explain why mucosal PIs cannot be staged. Keywords: medical device–related pressure injuries, mucosal pressure injuries, National Pressure Ulcer Ad- visory Panel, pressure injury, pressure injury staging, pressure ulcer, SORE mnemonic, DEVICE mnemonic ressure injuries (PIs), formerly known as bed- pressure ulcer was replaced by pressure injury to sores, decubiti, pressure sores, or pressure ul- underscore the fact that PIs may be present even Pcers, have been a nursing concern since the when the skin is intact, and the definitions of medi- time of Florence Nightingale. In April 2016, the Na- cal device–related PIs (MDRPIs) and mucosal mem- tional Pressure Ulcer Advisory Panel (NPUAP) shone brane PIs were revised.1 (See Figure 1 for a depiction a spotlight on this issue by convening a consensus of intact, undamaged skin.) The NPUAP currently conference in which associated terminology and defines MDRPIs as PIs that “result from the use of staging definitions were updated.
Pressure Ulcer Staging Guide

Pressure Ulcer Staging Guide Pressure Ulcer Staging Guide STAGE I STAGE IV Intact skin with non-blanchable Full thickness tissue loss with exposed redness of a localized area usually Reddened area bone, tendon, or muscle. Slough or eschar may be present on some parts Epidermis over a bony prominence. Darkly Epidermis pigmented skin may not have of the wound bed. Often includes undermining and tunneling. The depth visible blanching; its color may Dermis of a stage IV pressure ulcer varies by Dermis differ from the surrounding area. anatomical location. The bridge of the This area may be painful, firm, soft, nose, ear, occiput, and malleolus do not warmer, or cooler as compared to have subcutaneous tissue and these adjacent tissue. Stage I may be Adipose tissue ulcers can be shallow. Stage IV ulcers Adipose tissue difficult to detect in individuals with can extend into muscle and/or Muscle dark skin tones. May indicate "at supporting structures (e.g., fascia, Muscle risk" persons (a heralding sign of Bone tendon, or joint capsule) making risk). osteomyelitis possible. Exposed bone/ Bone tendon is visible or directly palpable. STAGE II DEEP TISSUE INJURY Partial thickness loss of dermis Blister Purple or maroon localized area of Reddened area presenting as a shallow open ulcer discolored intact skin or blood-filled Epidermis with a red pink wound bed, without Epidermis blister due to damage of underlying soft slough. May also present as an tissue from pressure and/or shear. The intact or open/ruptured serum-filled Dermis area may be preceded by tissue that is Dermis blister.
Healthcare Inspections

Department of Veterans Affairs Office of Inspector General Office of Healthcare Inspections Report No. 16-02998-345 Healthcare Inspection Pressure Ulcer Prevention and Management VA New York Harbor Healthcare System New York, New York August 17, 2017 Washington, DC 20420 In addition to general privacy laws that govern release of medical information, disclosure of certain veteran health or other private information may be prohibited by various Federal statutes including, but not limited to, 38 U.S.C. §§ 5701, 5705, and 7332, absent an exemption or other specified circumstances. As mandated by law, OIG adheres to privacy and confidentiality laws and regulations protecting veteran health or other private information in this report. To Report Suspected Wrongdoing in VA Programs and Operations: Telephone: 1-800-488-8244 Web site: www.va.gov/oig Pressure Ulcer Prevention and Management, VA New York Harbor Healthcare System, NY, NY Table of Contents Page Executive Summary ................................................................................................... i Purpose....................................................................................................................... 1 Background ................................................................................................................ 1 Scope and Methodology............................................................................................ 4 Patient Case Summaries ..........................................................................................
PREVENTING PRESSURE ULCERS in HOSPITALS: Preventing Pressure Ulcers in Hospitals

PREVENTING PRESSURE ULCERS IN HOSPITALS: Preventing Pressure Ulcers in Hospitals A Toolkit for Improving Quality of Care Authors Dan Berlowitz, M.D., M.P.H., Bedford VA Hospital and Boston University School of Public Health; Carol VanDeusen Lukas, Ed.D., VA Boston Healthcare System and Boston University School of Public Health; Victoria Parker, Ed.M., D.B.A., Andrea Niederhauser, M.P.H., Jason Silver, M.P.H., and Caroline Logan, M.P.H., Boston University School of Public Health; Elizabeth Ayello, Ph.D., RN, APRN, BC, CWOCN, FAPWCA, FAAN, Excelsior College School of Nursing, Albany, New York; and Karen Zulkowski, D.N.S., RN, CWS, Montana State University-Bozeman. This project was funded under contract number HHSA 290200600012 TO #5 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the U.S. Department of Health and Human Services. Additional support was provided through the U.S. Department of Veterans Affairs under grant # RRP 09-112. Acknowledgments The development of this toolkit was facilitated by the assistance of quality improvement teams at six medical centers: Billings Clinic, Boston Medical Center, Denver Health Medical Center, Montefiore Medical Center, VA Connecticut Healthcare System (West Haven Campus) and VA North Texas Healthcare System (Dallas Campus). We thank them for their valuable contributions. We also thank Barbara Bates Jensen, Ph.D., RN; Sharon Baranoski, M.S.N., RN, CWCN, APN, FAAN; Joy Edvalson, M.S.N., RN, FNP, CWOCN; Aline Holmes, M.S.N., RN; Diane Langemo, Ph.D., RN, FAAN; Courtney Lyder, Ph.D., RN; and George Taler, M.D., for their advice on this document.
Guideline: Assessment and Treatment of Pressure Ulcers in Adults & Children

British Columbia Provincial Nursing Skin and Wound Committee Guideline: Assessment and Treatment of Pressure Ulcers in Adults & Children Developed by the BC Provincial Nursing Skin & Wound Committee in collaboration with Wound Clinicians from: / TITLE Guideline: Assessment and Treatment of Pressure Ulcers in Adults & Children1 Practice Level Nurses in accordance with health authority / agency policy. Care of clients 2 with pressure ulcers requires an interprofessional approach to provide comprehensive, evidence-based assessment and treatment. This clinical practice guideline focuses solely on the role of the nurse, as one member of the interprofessional team providing care to these clients. Background Researching existing data on pressure ulcer prevalence rates in Canada, Woodbury and Houghton (2004) found that mean pressure ulcer prevalence was 25.1% in acute care, 29.9% in non-acute care settings and 15.1% in community care with an overall mean prevalence rate of 26% across all settings.39 This prevalence data illustrates the significance of the problem and the need for consistent, evidence-based care. In pediatrics settings, a US multi-site national study found that the overall prevalence of skin breakdown was 18%, of which 4% was attributed to pressure ulcers.17 Pressure ulcers occur most commonly over bony prominences but can occur anywhere on the body when pressure, shearing force and friction are present and can lead to the death of underlying tissues. Heels and the sacrum are the two most common sites for pressure ulcers. Animal model studies have shown that a constant external pressure of 2 hours or longer can result in irreversible tissue damage.12 Populations at increased risk for pressure ulcers include those who have problems with peripheral circulation, are malnourished (overweight or underweight), have motor or sensory deficits, are incontinent, are immune compromised, have diabetes, renal failure, sepsis and/or cardiovascular problems or have had lower extremity surgery, especially hip replacements.
Development of a Tool for Pressure Ulcer Risk Assessment And

University of South Florida Scholar Commons Graduate Theses and Dissertations Graduate School January 2012 Development of a Tool for Pressure Ulcer Risk Assessment and Preventive Interventions in Ancillary Services Patients Monica Shutts Messer University of South Florida, [email protected] Follow this and additional works at: http://scholarcommons.usf.edu/etd Part of the American Studies Commons, and the Nursing Commons Scholar Commons Citation Messer, Monica Shutts, "Development of a Tool for Pressure Ulcer Risk Assessment and Preventive Interventions in Ancillary Services Patients" (2012). Graduate Theses and Dissertations. http://scholarcommons.usf.edu/etd/4161 This Dissertation is brought to you for free and open access by the Graduate School at Scholar Commons. It has been accepted for inclusion in Graduate Theses and Dissertations by an authorized administrator of Scholar Commons. For more information, please contact [email protected]. Development of a Tool for Pressure Ulcer Risk Assessment and Preventive Interventions in Ancillary Services Patients by Monica S. Messer A dissertation proposal submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy College of Nursing University of South Florida Major Professor: Maureen Groer, Ph.D. Roger Boothroyd, Ph.D. Christine M. Olney, Ph.D. Annette Wysocki, Ph.D. Date of Approval: March 23, 2012 Keywords: Interface Pressures, Shear, Tissue Tolerance, Comorbidities, Tissue Oxygen Homeostasis Copyright © 2012, Monica S. Messer Dedication I wish to dedicate this dissertation to my greatest supporter and unwavering champion throughout the years of this pursuit; my beloved husband, James. You have truly been the wind beneath my wings, and without you there would not have been the incredible lift required for such a lofty flight.
Preventing Pressure Injuries

Issue 25 July 2016 Preventing pressure injuries Addendum: Page 4, July 2018 Issue: Pressure injuries are significant health issues and one of the biggest challenges organizations face on a day-to- day basis. Aside from the high cost of treatment, pressure injuries also have a great impact on patients’ lives and on the provider’s ability to render appropriate care to patients. Preventing pressure injuries has always been a challenge, not just for caregivers, but also for the health care industry as a whole, because the epidemiology of pressure injuries varies by clinical setting, and is a potentially preventable condition. The development of pressure ulcers or injuries can interfere with the patient’s functional recovery, may be complicated by pain and infection, and can contribute to longer hospital stays. The presence of pressure ulcers is a marker of poor overall prognosis and may contribute to premature mortality in some patients.1 In addition, the development of Stage 3 and 4 pressure ulcers (see the section below for definitions) is currently considered by The Joint Commission as a patient safety event that could be a sentinel event. Pressure injuries are commonly seen in high-risk populations, such as the elderly and those who are very ill. Critical care patients are at high risk for development of pressure ulcers because of the increased use of devices, hemodynamic instability and the use of vasoactive drugs. In 2008, the Centers for Medicare and Medicaid Services (CMS) announced it will not pay for additional costs incurred for hospital-acquired pressure ulcers.2 Pressure ulcer treatment is costly, but the development of pressure ulcers can be prevented by the use of evidence-based nursing practice.