CNA Pressure Ulcer Prevention Review

2. “Under Pressure”

3.  Learner will be able to define “what is a
pressure ulcer”—how one is formed
 Learner will be able to list 5 risk factors—from
Intrinsic and extrinsic risk factors
 Learner will be able to locate 5 pressure
points on a bedridden patient
 Learner will be able to describe 5 measures
which help prevent pressure ulcers

4.  “A pressure ulcer is localized injury to the skin
and/or underlying tissue, usually over a bony
area, as a result of pressure, or pressure in
combination with shear.”

5. Initially, skin is pale due to reduced blood
flow and inadequate oxygen supply.
 Skin will return to normal color if disruption
of blood flow occurred for a short period.
If prolonged pressure, blood cells aggregate
and block capillaries. Results—non-blanchable
erythema—stage I.

6. Unstageable Suspected Deep
Tissue Injury

7. Localized pressure is thought to contribute to pressure ulcer
development by deforming skin and soft tissues, often between a
bony structure and an external surface (such as a bed or a chair),
reducing blood flow and inducing ischemia (decrease oxygen
supply) and necrosis (tissue death).
Pressure on
deep artery

8.  Tissue damage is related to duration and force
of pressure applied.
 Pressure on the skin has been shown to produce
greater reductions in blood flow in a deep artery
than in skin capillaries (smallest blood vessels).
 Damage is highest in the soft tissues closest to
the bone.
 C/o burning is one of the earliest indicators of
pressure ulcer development.
 Patients at highest risk are those who are unable
to move or to ask to be moved.

9. Excessive pressure over time: often related to
decreased movement.
“Pressure is defined as the amount of force
applied perpendicular to a surface per unit
area of that surface.”
A force applied over a small area will produce
greater pressure than the same force applied
over a larger area.

10. Same
amount of
force applied
to both areas
of
application
X Force X Force
Area of
application
(body
surface)
More pressure Less pressure
Pressure = Perpendicular force
Surface area

11. Pressure is more evenly
distributed along the foot.
Your foot is less likely to hurt!
Pressure is greater on heel and at
front sole

12. Pressure Redistribution
Increased Contact Area Pressure Relief
Patient
Repositioning: to
increase contact area
eg. No more than a
30 degree tilt
Reactive support
surfaces: foam, gel or
air filled, air fluidized
Patient Repositioning:
to remove pressure
from a particular area
Active
support: eg.
Alternating
pressure
with
specialty bed
Lifting body
part: eg. Heel
boots, trapeze

13. Shear stresses arise from forces
applied tangentially to a surface and
causes the object to become
deformed.

14. Object before application of
external force
Tangential
(parallel) force
Application of tangential force
produces deformation and shear
stress
Angle produced by
deformation = shear strain

15. Shear force or a force created when the skin of
a patient stays in one place as the deep fascia
and skeletal muscle slide down with gravity.
This can also cause the pinching off of blood
vessels which may lead to ischemia and tissue
necrosis. Bedridden patients and wheelchair
users in half-sitting position are very
vulnerable for shear wounds.

16.  Skin friction is the force caused when two
touching surfaces move in opposite
directions and may result in superficial
scuffing or abrasion of the skin.

17.  Friction is affected by:
 Nature of fabrics touching the skin: rough fabrics
cause resistance to movement force
 Amount of perpendicular pressure applied: skin
 Moistness of skin: skin that stays moist is more
likely to be exposed to higher level of friction
 Surrounding humidity: high levels of humidity
increase skin moisture

18.  Assess head-to-toe those at risk from shear
stresses/friction:
 Once a shift
 More if condition warrants

19.  Provide care for those at risk
 Skin Care:
▪ Do not rub reddened areas
▪ Apply lotions gently and only use those that do not
leave a sticky residue
▪ Control skin dampness or maceration (prune looking
skin).
▪ Consider using a protective dressing to areas at risk

20.  Provide care to those at risk
 Positioning:
▪ Select a suitable position which minimizes the pressure
and shear exerted
▪ Limit head-of-bed to 30 degrees , unless medically
contraindicated
▪ 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 pressure
on the sacrum and coccyx (tail bones).

21.  Support Surfaces: choose the correct bed

22.  Choose devices that protect skin

23.  In the context of pressure ulcers,
microclimate usually refers to skin
temperature and moisture conditions at the
skin/support surface contact.

24.  Consists of 3 factors:
 Skin moisture: the presence of fluid on the skin
surface from perspiration, incontinence, or
wound/fistula drainage, or the actual moisture
content of the outer layers of skin.
 Air movement: can modify temperature and
humidity/skin moisture.
 Skin surface temperature: increased temperature may
be related to ulcer susceptibility by weakening the
stratum corneum (outer layer of skin).

25.  Raised body temperature is a risk factor for
pressure ulcers development by increasing
cell activity and increasing cell oxygen and
nutrient needs.
 If body temperature is raised 1 degree
Celsius, metabolic activity is raised by 10 %.
 If increases in energy and oxygen cannot be
met, ischemia ( areas with decreased blood
and oxygen supplies) occurs and pressure
ulcers can develop more quickly.

26.  Increased skin temperature may play a role in
the development of pressure ulcers by
weakening skin’s outer layers.
 Example: skin temperature that is 35 degrees
Celsius has only 25% of the mechanical
strength of skin that has a temperature of 30
degrees C. (Surface skin temperature is lower
than internal body temperature).

27.  Ageing skin is less
resilient and more easily
damaged than is
younger skin.
 Generally thinner
 Reduced lipid (oil) levels
and water content
 Has decreased stretch and
flexibility.
 Environmental humidity
should not be below 40%
to reduce the likelihood of
dry skin.

28.  Excessive moisture
on the skin surface—
perspiration, urinary
or fecal incontinence,
wound/fistula
drainage or vomit, is
thought to contribute
to increased risk for
the development of
pressure ulceration.

29.  Air flow can:
 Decrease temperature
 Can decrease skin moisture
 Although no hard evidence exists that link air flow
with pressure ulcer prevention, it is known that
excessively moist skin is more prone to break-down.

30.  Repositioning:
 Gets pressure off areas
 Allows skin exposed to cool and dry

31.  Skin care:
 Manage incontinence if possible
 Use barrier creams and sprays
 Use breathable underpads: only use one underpad
as multiple layers defeat bed’s therapeutic
mechanisms.
 Use lotions for dry skin
 Keep sheets and clothes dry

32.  Patients that cannot move or will not move
 Patients that are sedated
 Patients with underlying medical conditions
which can decrease perfusion (diabetes,
hypertension, cardiac conditions which
predispose to edema, dehydration….)
 Older patients ( dry skin, circulatory issues…)
 Malnourished patients
 Bariatric patients

33. Perpendicular force applied to small
area results in extreme pressure to
that area. High risk for pressure
ulcer.
No pressure applied to bony heel. Perpendicular force is over larger
area which creates much less pressure.

35. Place pillow/cushion long-ways unde. r lower extremity to elevate heel and
not to place pressure on popliteal artery. By placing the pillow long-ways, we
can increase the surface area and have better support as opposed to placing
the pillow horizontally

36.  Accurately document food intake
 All patients should receive a balanced diet if
able to take food by mouth
 Vegetables, fruits, meats and eggs, grains, dairy
 Calories and vitamins keeps patients from loosing
weight. *Remember, very thin patients are high
risk for pressure ulcers.
 If patients don’t eat adequate amounts,
report to nurses. Nurses can contact a
dietician who can offer supplements.

37. Patients in spica casts need to be
turned every 2 hours during the day
and every 6-8 hours during the night.
Patients can be log-rolled using the bar
as the casts are now made of fiberglass
instead of plaster as in the old
technique.

38.  Patients with spica casts can turn from front
to back and be placed on their sides.
 Maintain the cast in general alignment with
the chest and shoulder blades to prevent it
from pressing inward.
 Prone: keep toes off the mattress by placing a
support under the ankle.
 Supine: keep heels free of pressure by using a
rolled towel or small pillow.

39. Patients with hip, pelvic, or leg fractures with good upper body strength can
take the pressure off their sacrums by lifting every 30 minutes. The trapeze is
also useful to lift for a bedpan. Can you see what is wrong in the left pane?

40.  Occipital ulcers can
develop quickly due to the
large occiput (round back
of head) and little fat
padding.
 Using at least 2 caregivers,
loosen the c-collar, clean
neck, change pads, and
assess skin under the collar.
Patients wearing a c-collar
still need to be turned q 2
hours and occiputs should
be assessed with each turn.

41.  Can you explain what a pressure ulcer is and
how one is formed?
 Can you name risk factors?
 Can you name measures to prevent pressure
ulcers?
 Can you name several pressure
points?

42.  https://www.youtube.com/watch?v=rAMzhcb
tHJY