Pressure Ulcer Assessment and Treatment
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Pressure Ulcer Assessment and Treatment
Copyright © 2014 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to prepare healthcare professionals to prevent, assess, and treat pressure ulcers in their patients.
Upon completion of this course, you will be able to:
- Discuss the impact of pressure ulcers on individuals, healthcare facilities, and society.
- Explain the risk factors for developing pressure ulcers.
- Explain the process of conducting risk assessments and measuring risk associated with pressure ulcers.
- Identify actions to help prevent pressure ulcers.
- Describe the staging of pressure ulcers.
- Discuss effective wound treatment and management of pressure ulcers.
- Describe the factors affecting pressure ulcer healing.
- List the essential information for documentation of pressure ulcers in the patient record.
TABLE OF CONTENTS
A pressure ulcer is a wound unlike any other, in that its cause is not surgery or trauma but death of the skin and underlying tissues from ischemia due to unrelieved pressure. There are many factors that contribute to the development of a pressure ulcer and whether or not it will heal, but the biggest factor in all of these is pressure.
Common terms for a pressure ulcer include bedsore, decubitus ulcer, pressure sore, and pressure ulcer. The terms bedsore and decubitus ulcer originated from the notion that to develop ulcers a person needed to be bedridden, which we now know is not the case. Ulcers can develop when a patient constantly maintains any position; consequently the term pressure ulcer most accurately describes an ulcer from pressure.
Over the years, the definition of a pressure ulcer has been refined. The most recent definition from the National Pressure Ulcer Advisory Panel states that a pressure ulcer is “a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction” (EPUAP/NPUAP, 2009).
The compression of soft tissue interferes with the tissue’s blood supply, leading to vascular insufficiency, tissue anoxia, and cell death. Pressure ulcers can develop within 24 hours of the initial pressure but take as long as a week to present themselves. The first tissues to die are nearest the bone, and as the pressure and anoxia continue, the remaining layers of tissue begin to die. The skin is the last to die. The damage resembles an iceberg, with a smaller amount of damage visible at the surface and a large amount of damage below the surface.
Pressure ulcers usually occur over bony prominences such as the sacrum, ischium, heel, and trochanter, where there is less tissue to compress. Other factors—such as friction and shearing, poor nutrition, and incontinence—also contribute to the tissue breakdown.
THE IMPACT OF PRESSURE ULCERS
The most recent figures available indicate that 2.5 million patients are treated annually for pressure ulcers in acute care facilities in the United States (IHI, 2007). The impact of pressure ulcers is staggering.
- First and foremost, these wounds are very painful, thus causing patients a great deal of suffering.
- The anatomical location of the ulcer may result in a loss of dignity.
- Quality of life is affected, as the patient must alter activities to help heal the wound and may face long-term hospitalization.
- A nonhealing ulcer is at high risk for infection, which can be life threatening.
- Ulcer treatments may require surgical procedures such as debridement, colostomies, and amputations, which the patient would otherwise not have to face.
- An ulcer that heals forms scar tissue, which lacks the strength of the original tissue and is more easily ulcerated again and again.
- Most importantly, the presence of a pressure ulcer increases the risk of death. Nearly 60,000 hospital patients in the United States are estimated to die each year from complications due to hospital-acquired pressure ulcers (IHI, 2007). Likewise, actor Christopher Reeve, who had been a quadriplegic for the last nine years of his life, died from complications due to an infected pressure ulcer.
Healthcare costs increase dramatically due to pressure ulcers. An estimated $11 billion are spent each year to treat pressure ulcers. The inpatient length of stay is 3–5 times longer for those with a pressure ulcer. Patients with either a primary or secondary diagnosis of pressure ulcer are discharged to long-term care at three times the rate of other diagnoses (WOCN, 2010).
Pressure ulcers also increase healthcare practitioners’ workloads, as now additional time and care must be provided to manage and treat patients’ pressure ulcers—more dressing changes, more medications, and more documentation.
Litigation may be brought against a hospital and its staff for neglect, malpractice, and elder abuse if a patient develops a pressure ulcer while in the hospital. Awards can be in the millions of dollars. And the bad publicity that follows will damage the hospital’s reputation, bottom line, and trust patients have that they can be cared for safely.
Pressure ulcers are reportable to state and federal agencies. The information is placed in published reports accessible by the public, which then allows the public to compare facility outcomes. Regardless of the care setting (acute, SNF, home health, and inpatient rehabilitation facilities), all providers must account for the number of pressure ulcers that were present on admission and on subsequent reassessments, whether they have closed or worsened (Lyder & Ayello, 2012).
Governmental agencies may levy fines against the hospital for pressure ulcers. The Center for Medicare and Medicaid (CMS) no longer pays a hospital for the additional care needed for a patient who develops a hospital-acquired pressure ulcer (HAPU), but the hospital must provide the care nonetheless.
In the long-term care setting, the Joint Commission has again made the prevention of healthcare-associated pressure ulcers a 2014 National Patient Safety Goal (Joint Commission, 2013).
Thus, the assessment, prevention, and treatment of pressure ulcers are of major importance to healthcare professionals and to the facilities at which they practice. Many facilities have developed pressure ulcer prevention programs to put these ideas into practice and prevent negative outcomes.
The purpose of assessing the risk for developing pressure ulcers is to implement early detection and prevention measures. This is of utmost importance, as assessment without intervention is meaningless.
Risk Factors for Pressure Ulcers
Certain groups of patients have a higher risk for developing pressure ulcers. These include:
- Patients who are older adults (those over age 65 are at high risk and those over age 75 are at even greater risk)
- Patients in critical care
- Patients with a fractured hip (an increased risk for heel pressure ulcers)
- Patients with spinal cord injuries (spasticity, the extent of the paralysis, a younger age at onset, difficulty with practicing good skin care, and a delay in seeking treatment or implementing preventive measures increase the risk of skin breakdown)
- Individuals with diabetes, secondary to complications from peripheral neuropathy
- Individuals who are wheelchair- or bed-bound
- Patients who are immobile or for whom moving requires significant or taxing effort (i.e., morbidly obese)
- Patients who struggle with incontinence
- Patients with neuromuscular and progressive neurological disesases (i.e., multiple sclerosis, ALS, Myasthenia gravis, stroke)
Obvious changes in both skin structure and function occur with aging. These changes contribute to the occurrence of skin and wound problems.
- A flattening of the epidermal-dermal junction decreases the overall strength of the skin, which increases the risk for skin tears and blistering.
- A decrease in the melanocytes and Langerhans cells increases the risk for allergic reactions and sensitivity to sunlight.
- A decrease in blood flow decreases skin temperature.
- A decrease in oil and sweat production contributes to dryness and flaking.
- A decrease in subcutaneous tissue, especially fat, decreases the body’s natural insulation and padding.
- A decline in the reproduction of the outermost layer of the epidermis may lead to the skin’s inability to absorb topical medications.
These changes in skin structure and function, together with the risks that occur with a change in overall health and functional ability, put an aged patient at very high risk for the formation of a pressure ulcer.
There are other risk factors that may increase the chance of developing a pressure ulcer. More than 100 risk factors have been reported (WOCN, 2010). Some of these include:
- General medical conditions, such as diabetes, stroke, multiple sclerosis, cognitive impairment, cardiopulmonary disease, cancer, hemodynamic instability, peripheral vascular disease, malnutrition, and dehydration
- History of a previous pressure ulcer (since scar tissue is weaker than the skin it replaced and will breakdown easier than intact skin)
- Increased facility length-of-stay
- Undergoing surgery longer than 3 hours
- Significant weight loss
- Prolonged time on a stretcher, such as in the emergency room
- Medications, such as sedatives and analgesics
- Refusal of care, such as when a patient refuses to be turned or moved despite education
- Patient not being turned
- An ICU stay, due to the high acuity of illness, presence of multiple comorbid conditions, and:
- Mechanical ventilation
- Vasopressors and hemodynamic instability
- Multiple surgeries
- Increased length of stay
- Inability to report discomfort
Risk Assessment Schedules
The skin is the largest organ in the body, and the clinician needs to assess it regularly. The assessment of pressure ulcer risk should be performed when a patient is admitted to any healthcare setting. It should be repeated on a regular schedule per facility policy and/or when there is a significant change in the patient’s condition, such as surgery or a decline in health status (EPUAP/NPUAP, 2009).
A schedule for reassessing risk should be based on the acuity of the patient, judgment of the clinician, and knowledge of when pressure ulcers are most likely to occur in a clinical setting. Every patient must be assessed and reassessed, not just the ones who seem most likely to develop ulcers. In fact, a recent study (Bye et al., 2012) showed that in one hospital system, almost 25% of patients who had developed hospital-associated pressure ulcers had been identified as low risk. Recommendations based on the healthcare setting are included in the box below. A particular facility or setting may have different regulations.
ASSESSMENT SCHEDULES BY HEALTHCARE SETTING
Acute Care: In acute care, pressure ulcers can develop within the first 2 weeks of hospitalization. Elderly patients can develop pressure ulcers within the first week of hospitalization. The initial assessment is conducted upon admission and repeated at least every 24–48 hours, whenever the patient’s condition changes, or per facility policy. Most ICUs reassess each shift, while a medical-surgical unit may reassess daily.
Home Health: In home healthcare settings, most pressure ulcers develop within the first 4 weeks. The initial assessment is conducted upon admission and repeated at resumption of care, recertification, transfer or discharge, or whenever the patient’s condition changes. Some agencies reassess with each nursing visit.
Long-term Care: In long-term care settings, most pressure ulcers develop within the first 4 weeks. In skilled facilities, the initial assessment is conducted upon admission and repeated weekly thereafter. In nursing homes with long-term patients, the assessment is conducted upon admission, repeated weekly for the first month, and repeated monthly thereafter, or whenever the patient’s condition changes.
Source: WOCN, 2010.
What Needs to Be Assessed
Prevention of pressure ulcers must begin with frequent and routine assessment of the patient’s skin and of the risk factors that, if left unmanaged, will contribute to the development of an ulcer. A head-to-toe inspection of the skin must be done on admission and at least daily (or per facility regulation). The assessment should focus on high-risk areas such as bony prominences. The specific areas to assess are shown in the table and diagram below.
|If the patient’s position is:||Then focus on these areas:|
|Lateral||Ear, shoulder, trochanter, knee, ankle|
|Supine||Occiput, shoulder blades, elbows, sacrum, heels, toes|
|Semi-recumbent||Occiput, shoulder blades, elbows, sacrum, ischial tuberosities|
|Seated||Shoulder blades, spinal protrusions, elbows, sacrum, ischial tuberosities, heels|
Bony prominences are high-risk areas for pressure ulcers. (Source: © Invacare Corporation. Used with permission.)
Blanchable erythema is a reddened area that temporarily turns white or pale when pressure is applied with a fingertip. This is an early indication of pressure. Nonblanchable erythema is redness that persists when fingertip pressure is applied. It means that tissue damage has already occurred.
It can be difficult to identify skin problems in patients with dark skin. Redness may not be easy to see. The clinician needs to compare the at-risk area (such as the coccyx or hip) with skin next to it and look for color differences or changes in temperature or pain.
ASSESSMENT AND MEDICAL DEVICES
Medical devices such as shoes, heel and elbow protectors, splints, oxygen tubing, face masks, endotracheal tube holders, compression stockings, and others must be removed and the skin inspected daily. If the device cannot be removed—such as a nasogastric (NG) tube, urinary catheter, tracheostomy holder, or cast—then the skin around the device must be carefully inspected: the nares for an NG tube, the throat for a tracheostomy, the thigh for a urinary catheter, etc.
All such devices have caused pressure ulcers. Ulcers caused by medical devices are reportable to state and federal agencies, just as are those caused by pressure on bony prominences.
ASSESSMENT AND MOBILITY
Immobility is the most significant risk factor for pressure ulcer development. More frequent monitoring to prevent pressure ulcers is conducted for patients who have some degree of immobility, including those who are:
- Confined to bed, chairs, wheelchairs, recliners, or couches for long periods of time
- Paralyzed and/or have contractures
- Wearing orthopedic devices that limit function and range of motion
- Dependent on assistance to ambulate or reposition themselves
ASSESSMENT FOR FRICTION AND SHEARING
Friction is the mechanical force of two surfaces moving across each other; damage includes blisters or abrasions. Patients who cannot lift themselves during repositioning and transferring are at high risk for friction injuries. Shearing is the mechanical force that is parallel to the skin and damages deep tissues like muscle. Tissues attached to the bone are pulled in one direction while surface tissues remain in place. Shearing most commonly occurs when the head of the bed is elevated and the patient slides downward. Friction is most common when patients are turned or pulled up in bed.
ASSESSMENT FOR INCONTINENCE
Moisture from incontinence can contribute to pressure ulcer development by macerating the skin and increasing friction injuries. Fecal incontinence is an even greater risk for pressure ulcer development than urinary incontinence because the stool contains bacteria and enzymes that are caustic to the skin. When both urinary and fecal incontinence occur, the fecal enzymes convert the urea in the urine to ammonia, which raises the skin’s pH. When the skin pH is elevated (alkaline), the skin is more susceptible to damage. Pressure ulcers are four times more likely to develop in patients who are incontinent than in those who are continent (WOCN, 2010).
ASSESSMENT FOR NUTRITIONAL STATUS
Although individual nutrients and their specific role in preventing pressure ulcers have not been determined, malnutrition is associated with overall morbidity and mortality. A nutritional assessment should be conducted upon admission or when there is a change in the patient’s condition that would increase the risk of malnutrition, such as the patient’s refusal to eat or eating less than usual, prolonged NPO status, or development of a wound(s) or other conditions that increase metabolic demand.
Mr. Frank is a 90-year-old man who has been admitted to the hospital with pneumonia. He fell at home three months ago and was also hospitalized at that time. His equally elderly wife denies that she is having any difficulty caring for him and says that he eats well and takes all his medications.
The admitting nurse finds Mr. Frank to be very thin and that he weighs 10 pounds less than when he was hospitalized after his fall. His incontinence brief is saturated with urine, and his perineal skin is raw. He does not move himself in the bed. The nurse recognizes that Mr. Frank is at high risk for developing a pressure ulcer due to his poor nutrition, his immobility, and his incontinence.
The nurse discusses with the physician the patient’s need for a dietician referral, a pressure reduction mattress, and a barrier product to protect his skin. She alerts the discharge planner that Mr. Frank may require home health or possibly nursing home placement after the pneumonia is cleared, as his wife, despite her intentions, is having difficulty caring for her husband.
Determining Risk Levels
Several risk assessment tools or scales are available to help predict the risk of a pressure ulcer, based primarily on those assessments mentioned above. These tools consist of several categories, with scores that when added together determine the total risk score. The Braden and Norton Scales for predicting pressure ulcer risk are the most widely used in a variety of healthcare settings. The clinician uses these tools to help determine risk so that interventions can be started promptly. These tools are only used for assessing adults. For those who work with children, the Braden Q Scale has subcategories that relate to assessing children (see “Resources” at the end of this course).
The Braden Scale consists of six categories:
- Sensory perception: Can the patient respond to pressure-related discomfort?
- Moisture: What is the patient’s degree of exposure to incontinence, sweat, and drainage?
- Activity: What is the patient’s degree of physical activity?
- Mobility: Is the patient able to change and control body position?
- Nutrition: How much does the patient eat?
- Friction/shear: How much sliding/dragging does the patient undergo?
There are four subcategories in each of the first five categories and three subcategories in the last category. The scores in each of the subcategories are added together to calculate a total score, which ranges from 6–23. The higher the patient’s score, the lower his or her risk. (For more information, see “Resources” at the end of this course.)
- Less Than Mild Risk: ≥19
- Mild Risk: 15–18
- Moderate Risk: 13–14
- High Risk: 10–12
- Very High Risk: ≤9
It is recommended that if other risk factors are present—such as age, fever, poor protein intake, or diastolic blood pressure less than 60 mm Hg—the risk level should be advanced to the next level. Each deficit that is found when using the tool should be individually addressed, even if the total score is above 18. The best care occurs when the scale is used in conjunction with nursing judgment. Some patients will have high scores and still have risk factors that must be addressed, whereas others with low scores may be reasonably expected to recover so rapidly that those factors need not be addressed (Braden, 2012).
The very first pressure ulcer risk evaluation scale, called the Norton Scale, was created in 1962 and is still in use today in some facilities. It consists of five categories:
- Physical condition
- Mental condition
Each category is rated from 1 to 4, with a possible total score ranging from 5 to 20.
- Low risk: ≥18
- Medium Risk: 14–17
- High Risk: 10–13
- Very High Risk: <10
It is important that when the clinician uses a scale, the scale must not be altered in any way, meaning there cannot be shortcuts or changes to the definitions. Any changes would alter the accuracy and usefulness of the scale in predicting the risk of developing pressure ulcers.
Risk assessment is more than an act of determining a numerical score; it requires identification of those risk factors that contribute to that score and minimizing the deficits by the appropriateness of the intensity and effectiveness of prevention interventions (Kelechi et al., 2013).
PRESSURE ULCER PREVENTION
As the saying goes, “An ounce of prevention is worth a pound of cure.” It is more cost efficient to prevent a pressure ulcer than to cure one. Interventions that will help the clinician prevent pressure ulcers do so from both an outside and inside approach. From the outside, the clinician can minimize pressure through regular repositioning, using a support surface, and managing incontinence to prevent skin damage from moisture. The inside approach includes the management of nutrition and hydration to support the body in preventing damage and healing any damage that has occurred.
As previously stated, immobility is the most significant risk for the development of pressure ulcers. High pressures over bony prominences for a short time and low pressures over bony prominences for a long time are equally damaging (EPUAP/NPUAP, 2009). In order to decrease the risk, it is important to reduce the time and amount of pressure the patient is exposed to.
All patients must have their positions changed on a regular schedule. How often this is done is determined by each patient’s activity/mobility level, general medical condition, overall treatment plan, skin condition, and support surface.
To further assess a patient’s immobility, a referral to the physical therapist is most helpful in devising interventions and providing education to increase mobility. The therapist can educate the patient, family, and staff on safe ways to help keep the patient as mobile as possible.
For bed-bound patients, the standard “turn every two hours” may be more than adequate for some but not at all adequate for others. A patient needs to be repositioned more often on a standard mattress than on a pressure-redistributing mattress. If the medical condition is so severe that repositioning the patient regularly is not possible, then a support surface designed to decrease pressure must be used. For instance, a low air-loss mattress should be considered in this case.
Which support surface is available for use may depend on facility contracts and sometimes a patient’s insurance. A facility’s equipment department will indicate which options are available to the patient.
When we think of turning the patient, we often think that the patient must be completely over on a side. This can be difficult for the clinician/caregiver to do, is uncomfortable for the patient, can result in cardio-pulmonary compromise, and actually increases pressure on the side of the body.
Frequent small position changes, rather than completely turning the patient, is faster, easier, and safer for all. Any change in position is beneficial. The patient need only be tilted to the side, no more than 30 degrees, with pillows or wedges to help support and reduce the pressure over bony prominences. A small pillow behind the shoulder or the hip alters position without having to move the entire body. Bending the knee alters the pressure on the sacrum and hip. A small pillow behind the heel will elevate the heel off the surface and prevent pressure.
A small turn using a bolster can be as effective as a full turn. (Source: Author.)
When a patient is moved, it must be done in a way so as to prevent friction and shearing, as these forces will cause skin injury as readily as pressure.
- Always use a lift sheet or lift equipment to reposition the patient.
- The patient must be lifted, not dragged, while repositioning, which also means more than one person may be needed to move the patient. Pulling or dragging the patient will cause skin damage due to friction.
- Maintain the head of the bed at or below 30 degrees (or the lowest degree of elevation allowed based on the medical condition) to prevent the body from sliding down and causing a shear-related injury (WOCN, 2010).
- Lower the head of the bed one hour after meals or intermittent tube feedings. If this is not possible, the sacral region will need to be checked even more frequently for possible injury.
When moving a patient, always use good body mechanics and request help when needed. Have the patient assist in moving by using overhead trapeze bars. Even if the patient can only hold onto the bar, some of the weight will be reduced, making it easier and safer to move the patient. After the patient has been repositioned, be sure that he or she is not lying on a medical device, such as tubes or drains, and make sure the linens are smoothed.
A chair-bound patient must be repositioned as well. When a patient is seated, the weight of the body causes the greatest amount of pressure to occur over the ischial tuberosities. Since this area of the body is relatively small, the amount of pressure will be high; without pressure relief, a pressure ulcer will occur quickly. If the patient cannot sit upright but slouches in the chair, then the sacral area is at risk as well.
Recommendations for the chair-bound patient include:
- Stand the patient and reseat them in the chair.
- Elevate the legs or place the feet on a stool if the feet do not reach the floor. This will prevent sliding forward out of the chair.
- Elevate the feet and recline the chair by 30 degrees to reduce pressure.
- If the patient can change his/her own position, encourage pressure relief every 15 minutes. This includes chair pushups, leaning forward, leaning side to side, or tilting backwards. Leaning forward is the most effective and might be easier than chair push-ups.
- Acutely ill patients at risk for pressure ulcers should not sit for longer than two hours at a time and not return to sitting for at least an hour.
- Patients with existing pressure ulcers on the ischial areas should limit time sitting up in the chair to three times a day for 60 minutes or less, and they must use a cushion (gel or air cushions are best) that redistributes pressure (WOCN, 2010).
Physical and occupational therapists are of great importance in assessing and managing the immobile patient’s activities and instructing staff, patients, and families in proper techniques to avoid injury and prevent ulcers. This may include assessing the seating and positioning needs of individuals who are wheelchair-bound. Proper wheelchair positioning with an individualized seating system can promote good posture, enhance breathing and digestion, prevent complications such as pressure sores and skin irritation, slow further loss of mobility, minimize pain, and maximize functioning. Components of a wheelchair seating system may include specialized supportive cushions, backrests, headrests, and trunk, arm, and leg supports.
Patricia is a 61-year-old female with multiple sclerosis, leaving her bedridden and unable to move her legs. Despite being on a pressure reduction surface, she has developed a stage III pressure ulcer at her sacrum because of refusing to be turned due to the severe pain she experiences each time her right leg is moved. This has made it very difficult for the staff to provide wound care and keep Patricia clean. Furthermore, pain medication has not been effective for Patricia’s very intense but brief pain.
The nurse asks the physical therapist for recommendations to make moving Patricia less painful for her and less stressful for the staff. After assessing Patricia, the therapist directs using localized heat treatments to her right leg, gentle manipulation, and exercise. After several treatments with the therapist, Patricia is able to tolerate turning toward her right side and staying in position for the time needed to care for her wound and clean her. The therapist also instructs the staff about less painful ways to move Patricia’s leg when necessary. As a result, Patricia no longer screams out in pain when repositioned.
Using Support Surfaces
There is no mattress, cushion, or bed that will eliminate pressure and relieve the clinician or caregiver from having to turn the patient. Patients must still be turned, no matter what surface is used. Support surfaces on beds and chairs are used, however, to more evenly distribute body-weight pressure and to help reduce pressure to any one area of the body.
CHOOSING A SURFACE
Determining the appropriate support surface is based first on the patient’s condition and the healthcare setting. Overall, if the patient is able to be turned and has at least two intact turning surfaces, meaning the skin is intact on two sides of the body, then a mattress overlay or an alternating pressure pad can be used over a regular mattress. If the patient has skin breakdown on more than one side of the body, then a mattress replacement should be used.
Next, cost and product availability must be considered in choosing a surface. The healthcare setting will also determine the product used. For instance, in the home setting the weight of the bed, the structure of the home, the width of the doors, and the availability of uninterrupted electrical power will have a major impact on the support surface available for use.
In general, a standard hospital mattress should not be used with at-risk patients. Be sure to contact the medical equipment department to determine what is available for pressure reduction (WOCN, 2010).
Rings, foam cutouts, or donuts under the patient should not be used, as these concentrate pressure on surrounding tissue, causing swelling and decreasing circulation. The fact that they can be found in medical supply stores does not mean they are safe to use.
TYPES OF SUPPORT SURFACES
- Replacement mattresses: Mattresses with pressure-reducing features placed on an existing bed frame in place of a standard mattress
- Overlays: A support surface placed on top of a standard mattress; made of foam, water, gel, air, or a combination
- Foam: A thick slab of foam with a textured surface placed on top of a standard mattress to reduce pressure by surrounding the body; should be at least 3–4 inches thick to be effective at reducing pressure (2 inches is for comfort only)
- Water: A vinyl mattress or overlay with sections filled with water to distribute pressure more evenly and create a flotation effect
- Gel: Made of a thick fluid that conforms to the contours of the body
- Air: A vinyl mattress or overlay inflated with a blower to reduce pressure; powered or dynamic mattresses have a pump that inflates the mattress sections in an alternating cycle
- Low–air loss: A mattress or overlay with controlled air-flow sections
- Air-fluidized: Uses a high rate of blown air to fluidize fine particulate material (such as silicone beads) to “float” the patient on the surface
Rotational support systems (beds that rotate side to side automatically) are used to support pulmonary and circulatory function and are not sufficient for repositioning a patient to decrease the risk of a pressure ulcer. This is because the patient’s skin never leaves the bed surface and therefore pressure is not relieved off the skin.
For patients who spend most of their time sitting, proper support cushions are required. Pillows or pieces of foam might be comfortable, but they do not redistribute body weight to help decrease pressure.
In some healthcare settings, it is the occupational therapist who determines the correct support cushion; in others, it is the physical therapist. Nurses should not hesitate to refer the patient to either of these experts if needed.
ENSURING EFFECTIVENESS OF THE SUPPORT SURFACE
The support surface chosen must be approved for the patient’s body size and weight. Most conventional support surfaces are for patients who weigh 300 pounds or less. If the patient weighs more than this, then a bariatric mattress and frame must be obtained.
Even in patients who weigh less than the weight limit, where their weight is concentrated may make a difference in the mattress needed. The mattress may not be able to support the patient when the body weight is not evenly distributed. For instance, a paralyzed patient or an amputee may weigh under the limit, but most of the weight will be concentrated in the trunk.
If it looks as though the patient is lying or sitting in a “well,” the surface may not be able to support the patient’s weight. Provided the support surface is the correct one, check for any disconnected hoses or machine settings that may have been inadvertently changed. Contact the appropriate hospital department, supplier, or the manufacturer to have the support surface checked as needed.
With the use of any support surface, the number of linens and other items used under the patient must be kept at a minimum or the pressure-reducing ability of the surface will be altered significantly. Staff, patients, and family members must be instructed to use no more than two items between the patient and the surface, e.g., one pull sheet and one incontinence pad or product.
Regardless of the surface used, the patient’s heels must be floated off the bed using either a pillow or a heel-lift device. The recommended position for the pillow is lengthwise under the calf with the heel suspended off the pillow. The patient must still be turned at regular intervals to promote pulmonary, renal, and vascular function along with protecting skin integrity. Padded devices such as synthetic sheepskin, bunny boots, or rigid splints protect the heels from friction and shearing but do not relieve pressure. Devices such as an IV bag, rolled towel, or sheet do not redistribute pressure and can actually increase pressure (WOCN, 2010).
Heels are properly floated. (Source: Author.)
Skin moisture from incontinence is a risk factor for pressure ulcer development. Water saturates the skin, which increases the risk that friction and shearing will result in erosion of the skin. The ammonia in urine raises the skin’s pH, which promotes growth of pathogenic bacteria, disrupts the protective acid mantle, and activates fecal enzymes. Fecal enzymes damage the skin, allowing the gastrointestinal bacteria to cause infections. These result in a condition called incontinence-associated dermatitis (IAD). In and of itself, IAD is not a pressure ulcer. But if unrelieved pressure is added to IAD, the odds are five times higher that a pressure ulcer will develop. Proper cleansing and protection of the skin are the basis of prevention of IAD (Gray et al., 2012).
Cleanse the skin gently with a pH-balanced cleanser at each incidence of soiling. Perineal skin cleansers are more effective for prevention and treatment of IAD than traditional soap and water. This is because bar soap, which is alkaline and very drying, disrupts the skin’s protective abilities. Vigorous cleaning, as well as the use of rough washcloths, can also lead to skin erosion. Soft, disposable cloths are easier on the skin. Avoid cleaning products with fragrance or alcohol, as these are irritants. Some facilities use no-rinse foams, which are another good option.
An incontinence skin barrier product should be used to protect the skin after cleansing. Products such as creams, ointments, pastes, or those that form a film on the skin are all useful. Protective products with dimethicone, petroleum, or zinc oxide are recommended for patients with fecal incontinence or both urinary and fecal incontinence to protect against IAD. Several manufacturers offer products that both clean and protect, saving time for the caregiver and increasing the likelihood that perineal care will be performed.
Select underpads or incontinence briefs that are absorbent to wick moisture away from the skin instead of those that trap the moisture against the skin. However, all briefs increase moisture at the perineal region because they are occlusive and do not “breathe.” This creates warmth near the skin that, when combined with moisture, ammonia, and enzymes, increases skin breakdown. There is an increased risk with the use of briefs because they may not be changed as often as they should be due to the difficulty in seeing when a patient has voided. Briefs are not recommended for fecal incontinence because they can trap stool against the skin.
Many hospitals have moved away from using briefs except when a patient is ambulating or going off the ward. Instead, they use underpads that are especially designed to keep the skin dry and breathable and do not allow heat or moisture to be trapped against the skin.
A toileting program can also decrease incontinence and thus IAD. For those patients with significant fecal output, a pouching system or fecal containment device may be necessary to protect the skin from the effluent. In situations where the severity of urinary incontinence has contributed to or may contaminate an existing pressure ulcer, placing a urinary catheter may be indicated (WOCN, 2010).
|Sources: Palmer, 1996; Reichenbach, 1998a, 1998b.|
|Urge incontinence||Involuntary loss of urine with an abrupt strong need to void; occurs with the involuntary contractions of the detrusor muscle or uncontrolled urethral relaxation||Associated neurological disorders include stroke, paraplegia, multiple sclerosis, Parkinsonism, or dementia.|
|Stress incontinence||Involuntary leakage of small amounts of urine with a rise in intra-abdominal pressure that occurs during coughing, sneezing, laughing, and physical activity||Often seen in women; causes include estrogen deficiency, weakness in pelvic floor musculature, urethral sphincter weakness, childbirth, and obesity.|
|Functional incontinence||Individual with a functional urinary tract is unable or unwilling to get to the toilet to urinate||Often occurs in older adults; contributing factors include use of physical restraints, musculoskeletal dysfunction, unavailability of a urinal, visual impairment, impaired mobility, cognitive deficits, unfamiliarity of environment, and psychosocial difficulties.|
|Overflow incontinence||Involuntary loss of urine secondary to over distension of the bladder; results in the leakage of small amounts of urine due to an outflow obstruction or a hypotonic bladder||Common causes include medications, neurological conditions such as diabetic neuropathy or spinal cord injury, prostate enlargement, detrusor weakness, or urethra stricture.|
|Mixed incontinence||Combination of other types of urinary incontinence, typically urge and stress incontinence||Common in older adults|
OCCUPATIONAL THERAPY AND INCONTINENCE
Occupational therapists (OTs) are specialists in assessing and identifying the underlying impairments associated with urinary incontinence. Common interventions that can be implemented by OTs include:
- Pelvic Floor Muscle Training (PFMT): a program of repeated pelvic floor muscle contractions
- Scheduled toileting (i.e., timed voiding): monitoring and then matching of the individual’s typical toileting schedule
- Habit retraining: identifying the individual’s natural voiding pattern and developing an individualized toileting schedule
- Prompted voiding: establishing a routine in which a caregiver suggests voiding and provides assistance as needed
Research indicates that the use of a toileting routine in combination with medication and education results in decreasing urinary incontinence.
Ruth is an elderly woman living in a residential treatment facility. She has a stage IV pressure ulcer on her sacrum that the nurse is treating per the physician’s orders. The nurse has been educating the facility’s caregivers about the importance of keeping Ruth’s perineal skin clean, dry, and protected. Upon several instances of checking Ruth, however, the nurse finds both Ruth and her sacral dressing to be wet with urine. A caregiver also reports to the nurse that the dressing requires changing several times a day due to urine saturation.
The nurse knows that exposure to urine can delay or prevent wound healing. Remembering that frequent dressing changes can also delay healing, the nurse advises the physician of Ruth’s incontinence and wound status. The physician writes an order for an indwelling urinary catheter. The nurse inserts the catheter per protocol and instructs the caregivers in its maintenance. When assessing Ruth after a couple of days, the nurse notes that the catheter has kept Ruth and the sacral dressing dry, resulting in improvement of her wound.
Malnutrition is associated with overall morbidity and mortality. Thus, assessing the patient’s nutritional status must be part of the total assessment for pressure ulcers. A nutrition assessment should be performed upon admission and whenever there is a change in the patient’s condition that puts him or her at risk for malnutrition.
NUTRITION ASSESSMENT PARAMETERS
- Current weight and usual weight
- History of unintentional weight loss or gain (>5% change in 30 days or >10% change in 180 days)
- Body mass index (BMI)
- Food intake
- Dental health
- Ability to chew, swallow, and feed oneself
- Medical and/or surgical history that influences intake or absorption of nutrients
- Drug/food interactions
- Psychosocial factors that can affect food intake
- Ability to obtain and pay for food
- Facilities for cooking and eating
- Food preferences
- Cultural and lifestyle influences on food selection
- Over 65 years of age
The patient should be monitored for signs of dehydration, such as decreased skin turgor and/or urine output or elevated serum sodium. Serum protein tests, such as for albumin and pre-albumin, may be affected by inflammation, renal function, and hydration and so may not correspond with overall nutritional status. Thus, laboratory tests should be considered as only one part of the nutritional assessment.
While there is evidence that adequate nutritional support for stage III and IV pressure ulcers is a strong predictor of pressure ulcer healing and that support with high protein can significantly reduce the risk of pressure ulcers, there is no evidence to support that specific supplements promote the healing of ulcers. Studies that show support are few and more research needs to be done (WOCN, 2010).
Any patient with nutritional and pressure ulcer risks, suspected or identified nutritional deficiencies, or a need for nutritional supplementation to prevent undernutrition should be referred to a registered dietician. Any patient with a pressure ulcer should be referred to the dietician as well (WOCN, 2010).
STAGING PRESSURE ULCERS
Pressure ulcers are staged to classify the degree of tissue damage that is present. The staging system was originally created in 1975 as a means to describe the amount of anatomical tissue loss in a pressure ulcer. The use of stages in pressure ulcer assessment is a way to classify the amount and type of tissue destroyed based on anatomic depth. Having and using a common classification system allows all clinicians a way of communicating accurately about what is wrong. It is only used to describe pressure ulcers, not other wounds.
The most current staging system from the National Pressure Ulcer Advisory Panel (EPUAP/NPUAP, 2009) is described below.
A stage I pressure ulcer is defined as intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue.
A blanchable redness means that when the red area is compressed by the finger, the area turns white or pale and the redness returns when the pressure is released. Nonblanchable redness means the area under the finger remains red as it is compressed. Nonblanchable redness indicates that tissue damage has already occurred. (See figure.)
Stage I pressure ulcer. (Sources: [illustration] © NPUAP, used with permission; [photo] © Wound, Ostomy and Continence Nurses Society (WOCN), used with permission.)
A stage II pressure ulcer refers to partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister or as a shiny or dry shallow ulcer without slough or bruising.
(Slough is a soft, moist, avascular tissue. It may be white, yellow, tan, or green; loose or firmly adherent; and described as resembling “chicken fat.” Bruising indicates deeper tissue injury.)
This stage should not be used to describe skin tears, tape burns, perineal dermatitis (incontinent-associated dermatitis), maceration, or excoriation. “Partial thickness” means that the damage is confined to the epidermis and/or dermis but does not penetrate below the dermis. (See figure.)
Stage II pressure ulcer. (Sources: [illustration] © NPUAP, used with permission; [photo] © WOCN, used with permission.)
A stage III pressure ulcer includes full-thickness tissue loss, meaning the damage extends completely through the dermis to the subcutaneous layer. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough and/or eschar may be present but does not obscure the depth of tissue loss. The ulcer may include undermining (tissue destruction to underlying, intact skin along the wound edges) and tunneling (a path of tissue destruction that occurs in any direction from the surface or edge of the wound).
(Eschar is black or brown necrotic tissue. It can be loose or firmly adherent; hard, soft, or boggy; and look like a scab, although there is no healing occurring beneath it.)
The depth of 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 here will be shallow. In contrast, areas of significant fat deposits can develop extremely deep stage III pressure ulcers. (See figure.)
Stage III pressure ulcer. (Sources: [illustration] © NPUAP, used with permission; [photo] © WOCN, used with permission.)
A stage IV pressure ulcer involves full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. It often includes undermining and tunneling.
The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and stage IV ulcers here will be shallow.
Stage IV ulcers can extend into muscle and/or supporting structures, such as fascia, tendons, or joint capsules, making osteomyelitis possible. Exposed bone or tendon is visible or directly palpable. (See figure.)
Stage IV pressure ulcer. (Sources: [illustration] © NPUAP, used with permission; [photo] © Association for the Advancement of Wound Care (AAWC), used with permission.)
Suspected Deep Tissue Injury
The NPUAP has also described two additional categories of pressure ulcer: suspected deep tissue injury and unstageable (EPUAP/NPUAP, 2009).
Deep tissue injury may be indicated by a purple or maroon localized area of discolored intact skin or a blood-filled blister due to damage to the underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Its evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. (See figure.)
Suspected deep tissue injury. (Sources: [illustration] © NPUAP, used with permission; [photos] © AAWC, used with permission.)
A pressure ulcer is considered unstageable in the case of full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown tissue) and/or eschar (tan, brown, or black tissue) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; however it will end up to be a stage III or IV, as slough and/or eschar do not form in stage I or II ulcers.
Stable eschar (dry, adherent, intact without erythema or fluctuance) on the heels serves as the body’s natural or biological cover and should not be removed. (See figure.)
This ulcer will continue to be described as unstageable.
Unstageable pressure ulcer. (Source: [illustration] © NPUAP, used with permission; [photo] © AAWC, used with permission.)
The term reverse staging came about in the 1980s as a way of describing improvement in an ulcer. However, this term does not accurately describe what is physiologically occurring in the ulcer. Because staging is used only to describe the amount and type of tissue destroyed based on anatomic depth, it cannot be used to describe healing.
As a pressure ulcer heals, it does decrease in depth, but the body does not replace the lost bone, muscle, subcutaneous fat, or dermis. Instead, the full-thickness ulcer is filled with granulation, or scar tissue, and then covered with new epithelium. Even a partial-thickness stage II ulcer does not return to the nonblanchable redness of a stage I ulcer. A stage IV pressure ulcer that has closed should be classified as a closed stage IV pressure ulcer and not as something like a stage O pressure ulcer (which does not exist).
The progress of healing a pressure ulcer can only be documented using wound characteristics (decrease in length, width, depth, odor, drainage, pain, etc.) or using a validated pressure ulcer healing tool. If a pressure ulcer reopens in the same anatomical site, the ulcer resumes the previous staging diagnosis—once a stage IV, always a stage IV (EPUAP/NPUAP, 2009).
PRESSURE ULCER TREATMENT
Treating a pressure ulcer involves all of the activities used in preventing a pressure ulcer: the proper pressure-reducing surface, repositioning the patient correctly and frequently, maintaining intact skin, and improving nutrition. While these interventions are started, the treatment of the wound itself also begins. There are basic wound-care principles that can be used in deciding which treatments will be the best for the wound and for the patient. Frequent reassessment of the wound and its response to the treatment is required, as well as eliminating or reducing the factors that inhibit wound healing.
Of all the interventions that must be done to heal the ulcer, pressure reduction measures are the most important. Simply put, the wound will not heal unless the pressure is removed. Trying to heal a pressure ulcer without reducing the pressure is like trying to heal a stab wound with the knife still in it. You might get some improvement, but the wound will never heal because the primary cause has not been removed.
Repositioning and turning must be done regularly and frequently. Friction and shear must be prevented or a small ulcer will quickly turn into a large one with undermining and tunneling. (A “classic” pressure ulcer is round; one that is misshapen with undermining and tunneling has had friction and shear placed on it.) The right support surface for the bed or the chair must be obtained and used. Management of incontinence will keep skin from getting worse. While outside impediments to healing are being managed, the inside impediments can be attended to through proper nutrition and by reducing other factors that affect healing.
Universal Principles of Wound Management
The object of treatment is to reproduce (to the best of one’s ability) the normal environment of the exposed tissue of the wound. The normal environment of all tissue and cells, with the exception of the epidermis, is warm, dark, moist, and protected. In order to heal any wound, including pressure ulcers, some basic principles need to be followed. These are:
- Remove necrotic tissue
- Treat infection
- Fill dead space
- Maintain a moist wound environment
- Protect the wound from infection, trauma, and cold
Some of these principles will require medical intervention; others, good clinical care. By following these principles, caregivers will provide the wound with the environment it needs to heal.
DEBRIDEMENT: REMOVING NECROTIC TISSUE
Removing necrotic tissue is the critical first step when healing the ulcer is the goal. By removing dead tissue, bacteria and the risk for infection are decreased as well as drainage and odor. Removing these materials may also contribute to the release of available growth factors in the wound, thus allowing the cells to multiply and heal the wound.
The removal of necrotic tissue is called debridement, of which there are several types. The most appropriate type of debridement will depend on the patient’s overall condition and goals of care. Factors to consider include the status of the ulcer; the type, quantity, and location of the necrotic tissue; the presence or absence of infection; pain tolerance; the care setting; and professional accessibility (EPUAP/NPUAP, 2009).
Removing the necrotic tissue will often reveal the true size of the ulcer and the damage done—the “iceberg” effect. The patient and family should be educated that the ulcer will look worse after debridement and that the ulcer cannot heal without debridement.
Performed by a surgeon at the bedside or in the operating room, surgical debridement is the quickest way to remove extensive necrotic tissue, undermining, and tunneling. The benefits of surgical debridement in the presence of advancing cellulitis, crepitus, fluctuance, and/or sepsis secondary to ulcer-related infection usually outweigh the risks. However, relative contraindications include anticoagulant therapy, bleeding disorders, and immune incompetence. If the necrotic ulcer is on a limb, a thorough vascular assessment is conducted prior to debridement to rule out arterial insufficiency. The NPUAP recommends against debridement of stable, hard, dry eschar in ischemic limbs (EPUAP/NPUAP, 2009).
Conservative, sharp debridement—as opposed to surgical debridement—may be performed by specially trained, competent, qualified, and licensed healthcare professionals consistent with local, legal, and regulatory statutes. Sharp debridement removes only loose, easily identifiable necrotic tissue.
This method allows the body to break down necrotic tissue by using its own enzymes and defense mechanisms. Autolytic debridement is accomplished with the use of occlusive dressings such as hydrocolloids and films. These dressings help maintain a moist wound environment, reduce pain, and provide a barrier to infections. The dressing is left on for a few days, allowing the accumulation of fluids and enzymes at the site. The dressing is removed, the wound cleansed, and new dressing applied. This method takes time but is effective.
This method involves the use of enzyme debriding agents. These agents break down necrotic tissue without affecting viable tissue. The enzyme product is applied daily to the necrotic tissue and then covered by a dressing. Enzymes are by prescription only, and currently only one is available on the market.
This method uses sterilized bottlefly maggots, which debride the wound by dissolving dead and infected tissue with their digestive enzymes (in other words, the maggots eat the dead tissue). The maggots also disinfect the wound by killing bacteria. This in turn stimulates the growth of healthy tissue. (For futher information, see “Resources” at the end of this course.)
Mechanical debridement utilizes physical forces to remove necrotic tissue.
In the past, the most common type of mechanical debridement was the use of wet-to-dry dressings and whirlpools, but wet-to-dry dressings are no longer recommended. In this method, wet gauze is applied to the wound and necrotic tissue is allowed to dry and then forcibly removed without re-wetting. The gauze will have stuck to the necrotic tissue, thus removing it when the gauze is removed. However, this method is nonselective in that healing tissue will also be removed, thus re-traumatizing the wound bed and causing significant pain. The use of whirlpools has also fallen out of favor due to the difficulty in assuring the equipment is free of pathogens before its use on the next patient.
High-pressure wound irrigation is now used with commercially available devices, such as pulsatile lavage units. A lower-pressure method to debride tissue is to use a 35-ml syringe with a 19-g needle held a few inches from the wound. Care must be taken to minimize splashing and exposure to wound drainage. Infection control precautions should be followed.
Infection is not common in stage I or II ulcers; therefore, assessing for infection is focused on stage III and IV ulcers. Pressure ulcers that are infected may exhibit subtle signs of infection—such as new or increased pain, delayed healing, poor or friable granulation tissue, discoloration of wound bed tissue, a change in odor, increased serous drainage, induration, or pocketing—before the classic signs of infection occur. There should be a high suspicion for the likelihood of infection in ulcers with necrotic tissue, those that have been present for a long time, those large in size, or those repeatedly contaminated, such as those near the anus.
It is important to look for local infection in ulcers that have no signs of healing after two weeks of treatment. An acute infection may be present if there is redness extending from the ulcer edge, warmth, purulent drainage and odor, increase in size of the ulcer, and increase in pain. Systemic symptoms such as fever and malaise may develop. The elderly may develop confusion and anorexia. There must also be a high suspicion for the likelihood of infection in patients who have diabetes, malnutrition, hypoxia, autoimmune disease, or immunosuppression.
The gold standard method of determining wound infection is by a culture of tissue obtained by biopsy. However, an acceptable alternative to a tissue culture is a swab culture obtained by the Levine technique (EPUAP/NPUAP, 2009).
LEVINE TECHNIQUE FOR WOUND CULTURE
- Cleanse wound with sterile normal saline; blot dry with sterile gauze.
- Culture the healthiest-looking tissue in the wound bed.
- Do not culture drainage, pus, necrotic tissue, or fibrous tissue.
- Rotate the end of a sterile alginate-tipped applicator over a 1 cm by 1 cm area for 5 seconds.
- Apply sufficient pressure with the swab to cause tissue fluid to be expressed.
- Send the specimen to the lab.
If the culture indicates infection, a two-week course of topical antibiotics is used to treat the infection. Consider systemic antibiotics if bacteremia, sepsis, advancing cellulitis, or osteomyelitis has occurred. Systemic antibiotics cannot reach necrotic tissue, so topical antibiotics are recommended in addition to systemic (EPUAP/NPUAP, 2009).
Silver- and honey-impregnated dressings are an option for ulcers infected with multiple organisms because these dressings offer broad antimicrobial coverage. Be sure the patient is not allergic to honey or to bees before using a honey dressing.
Topical antiseptics such as povidone iodine, Dakin’s solution, or acetic acid that are properly diluted may be used for a limited time to control the bacterial burden, clean the ulcer, and reduce surrounding inflammation. Once the wound is clean, these products should be discontinued, as they can be damaging to healthy tissue. These products can also be used to control bacteria, drainage, and odor in wounds that are not expected to heal, such as in a terminally ill patient (EPUAP/NPAUP, 2009).
Cleansing the wound will also reduce the risk of infection. The ulcer and the surrounding skin must be cleansed at each dressing change. The cleansing method should provide enough pressure to remove debris yet not enough to cause trauma to the wound bed. Techniques for cleansing may include irrigation, gently swabbing the wound, or showering.
Pressure ulcers that are healing may be cleansed with water; tap water, distilled water, cooled boiled water, or saline are all options. Avoid using cleansing products that are designed for use on intact skin, and avoid cleaners that are designed to remove fecal material; both of these can be toxic to a wound. When the wound has a lot of drainage or debris, a commercial wound cleanser may be used. Those that contain surfactants can help remove wound contaminants (WOCN, 2010).
FILLING DEAD SPACE AND MAINTAINING A MOIST ENVIRONMENT
Wound dressings are a central component of pressure ulcer care. The selection of the dressing for the ulcer is very important and based on many parameters, such as:
- Presence of infection or necrosis
- Size, depth, and presence of undermining or tunneling
- Condition of the surrounding skin
- Goals for healing
- Individual or caregiver needs, such as pain reduction or odor control
- Cost/reimbursement of the dressing
- Ease of use
Maintaining a moist wound is a primary factor in dressing selection. If the ulcer is draining a large amount, then a dressing that will absorb but not dry out the wound is needed. If the ulcer has minimal drainage, then a dressing that replaces moisture and/or doesn’t allow the ulcer to dry out is needed.
The “dead” space inside the wound needs to be filled so that the dressing is in contact with the wound bed, including any tunneling or undermining. A wound should not be stuffed with the dressing material; stuffing the wound puts pressure on the inside of the wound and will prevent exudate from draining out.
Dressings are changed based on the amount of drainage: a heavily draining wound will need to be changed often, while a minimally draining wound can be changed less than daily. There are many dressings available today to help maintain the correct environment to allow healing. It is important to follow manufacturer recommendations for the use of the product (Hess, 2013).
EXAMPLES OF DRESSING TYPES FOR PRESSURE ULCERS
Hydrocolloid (e.g., Duoderm): A type of dressing containing gel-forming agents applied to a foam or a film, which form an absorbent, self-adhesive, waterproof occlusive wafer. These dressings are used in stage II ulcers in body areas where they will not roll or melt. They are also used for autolytic debridement. Expect the formation and/or collection of drainage under the wafer. This does not indicate infection but is a property of the product. Do not use on infected or heavily draining wounds or wounds in which the dressing needs to be changed more than three times per week. Remove carefully.
Transparent film: Can be used to protect body areas at risk for friction injury. Can be used for autolytic debridement. May be used as a secondary dressing to hold in other dressings. Remove carefully.
Hydrogel: Water- or glycerin-based gel, impregnated gauzes, and sheet dressings used to add moisture to a wound. Generally, these dressings are used on shallow, minimally draining ulcers. They are covered with a secondary dressing.
Alginate: These are used in moderately and heavily draining ulcers. Cover with a secondary dressing.
Foams: Used in draining stage II and shallow stage III ulcers. They absorb drainage and protect the wound.
Gauze: A cotton or synthetic weave that is absorptive and permeable to water, water vapor, and oxygen. Gauze may be impregnated with petrolatum, antiseptics, or other agents. Gauze should not be used in clean ulcers, as they are labor-intensive to use, cause pain when removed if dry, and will dry out a wound. However, if no other dressing is available, the use of gauze that is kept continually moist is preferable to dry gauze. Moist gauze can be used to loosely fill a cavity wound and one with undermining and tunneling.
Negative Pressure Wound Therapy (NPWT): These mechanical systems include a vacuum pump, drainage tube, and dressing set. The use of NPWT has been associated with increased rates of healing in stage III and IV pressure ulcers. Necrotic tissue must be debrided prior to using NPWT. Follow manufacturer guidelines for use.
Silver-impregnated dressings: An antimicrobial dressing used in ulcers that are infected or at high risk for infection. The silver is incorporated into foam, alginate, and other dressings. The silver is activated when it comes in contact with wound fluid. Consider discontinuing use when infection is controlled and/or drainage reduces significantly. Can turn tissues a dark color. Do not use in patients allergic to silver.
Honey-impregnated dressings: FDA-approved manuka honey is used for antimicrobial effects and can be effective on antibiotic-resistant bacteria while promoting healing. Used in stage II, III, and IV ulcers. Assists in debridement. Do not use in patients allergic to bees or honey.
Cadexomer iodine: An antimicrobial dressing containing iodine that absorbs drainage and matter from the wound surface, and as it becomes moist, the iodine is released. Used in moderately to highly draining wounds. Do not use in patients with iodine sensitivity or thyroid disease. Difficult to use in large-cavity wounds.
Impregnated gauze dressings: A gauze dressing impregnated with polyhexethylene biguanide that provides a barrier to bacteria and inhibits the growth of bacteria in the dressing, thus protecting the wound and potential spread of bacteria from the wound. Used in place of plain gauze.
Many of the advanced dressings do not need to be changed daily, which reduces pain, time, and expense. Follow manufacturer directions.
PROTECTING THE WOUND FROM INFECTION, TRAUMA, AND COLD
Protecting the wound from infection, trauma, and cold can be done through the proper cleansing and dressing of the wound. As a wound heals and the drainage decreases, choose a dressing that does not have to be changed often. Every time a dressing is removed and the wound cleansed, the temperature of the wound bed drops to room temperature. The body then must expend energy to bring the wound bed back to body temperature so that cell repair and growth can continue. This can take several hours. Less-frequent dressing changes aid the wound in healing by giving it time to do so. Protecting the wound from trauma includes the proper support surface, protection from incontinence, and the use of dressings that do not need to be changed frequently.
With each dressing change, the ulcer is observed for anything that may indicate the need for a change in treatment—e.g., improvement or deterioration, more or less drainage, signs of infection, or other complications. Any signs of deterioration should be addressed immediately. The type of dressing may need to be changed based on this assessment. For example, an antimicrobial dressing may be needed, or a more absorptive dressing used, or a change made in frequency of wound care.
Stage I and II pressure ulcers should show evidence of healing within 1–2 weeks, and stage III and IV ulcers should show evidence of healing within 2–4 weeks. This means that if after two weeks of treatment there has been no healing or signs of improvement, then all the risk factors need to be reevaluated and the plan of care revised to reflect new interventions.
HEALING ASSESSMENT TOOLS
There are several tools for assessing pressure ulcer healing. The Bates-Jensen Wound Assessment Tool (BWAT) is comprised of fifteen items, of which thirteen are scored from 1–5. The total scores and dates of assessment can be plotted on a graph, which provides an index of improvement or deterioration of the wound. (See “Resources” at the end of this course.)
The PUSH tool (Pressure Ulcer Scale for Healing) was developed by NPUAP. An ulcer is categorized using numerical scores of 0–5 according to surface area (length times width), drainage amount, and tissue type. A comparison of the total scores measured over time provides an indication of improvement or deterioration in the ulcer.
Many computer systems also have programs to monitor ulcer progress. Of course, the clinician will also use clinical judgment to assess signs of healing, such as a decrease in the amount of drainage, pain, and wound size and an improvement in wound bed tissue. The clinician can also use photography, comparing baseline and serial photographs to monitor healing over time. Follow facility policy on the use of photography.
FACTORS THAT AFFECT WOUND HEALING
In the case of a nonhealing pressure ulcer, when the choice of wound care is appropriate and pressure is being relieved, then the patient needs to be reassessed for other reasons why the ulcer is not improving. One systematic approach to determining what other factors might be affecting wound healing utilizes the acronym DIDN’T HEAL. Using this acronym and correcting those factors that can be corrected will aid in healing the ulcer. If factors cannot be corrected, healing the ulcer may not be possible.
|Source: Stillman, 2010.|
|Diabetes||Lack of diabetic control affects wound healing by causing diminished cardiac output, poor peripheral perfusion, and a decrease in the ability of WBCs to function||
|Infection||Increases the destruction of collagen needed for repair||
|Drugs||Can impair collagen synthesis||
|Nutrition||Deficiencies impair normal wound healing||
|Tissue necrosis||Impairs wound healing due to lack of oxygen||
|Hypoxia||Inadequate tissue oxygenation||
|Excessive tension||Tension on wound edges leads to local tissue ischemia and necrosis||
|Another wound||Competition for all the factors needed for wound healing impairs wound healing at all sites||
|Low temperature||Further deceases oxygen to the wound||
DETERMINING THE NEED FOR SURGICAL INTERVENTION
A patient with a stage III or IV ulcer that has not responded to conservative medical treatment may be evaluated for operative repair. Prior to surgery the patient should be in an optimal state both mentally and physically, and factors that impair healing should be minimized. The patient’s ability to tolerate the surgery and participate in the postoperative rehabilitation must be assessed prior to any surgery. Some patients may not be surgical candidates due to malnutrition, immobility, poor compliance with treatment, or chronic diseases.
Operative procedures may include skin grafts or flaps (surgical reconstruction). Which option is available may be limited due to previous surgeries, a shortage of available tissue to use, and impaired blood supply. Immediately after surgery, the operated region must be totally offloaded. Once the surgical incision has healed, the patient will be allowed to gradually apply pressure to the area.
Rates of surgical complications and recurrence rates are high. Complication rates have been reported as high as 49%. Osteomyelitis is the major cause of breakdown after surgery (WOCN, 2010).
The very basics of documentation are to document what was observed, what was done (including education provided), and how the patient responded. Documentation of pressure ulcer management includes an assessment of the ulcer on admission and at least weekly thereafter (or per agency regulations) for any signs of skin and/or wound deterioration, along with documentation of risk assessment and patient/family education provided. The following parameters are also documented:
- Onset, course, and duration of the ulcer
- Description of the ulcer
- Pain (location, intensity, quality, onset, duration, alleviating/aggravating factors)
- Patient/caregiver’s ability and willingness to adhere to the prevention and treatment program
- Prevention interventions that were initiated (referrals to dietary, physical therapy, occupational therapy, support surface management, skin care management, etc.)
- Discussions conducted with, and observations made by physicians
The description of the ulcer includes the physical characteristics of the ulcer itself and of at least 4 cm of the surrounding tissue (Hess, 2013). The following factors should be included in the documentation of any wound.
Describe where on the body the wound is, including the nearest bony prominence or anatomic landmark. Descriptors such as anterior-posterior, medial-lateral, or proximal-distal can clarify location.
Use the staging definitions described earlier in this course.
DRAINAGE OR EXUDATE
- Amount: Light or scant, moderate, heavy or large, copious
- Color: Serous (clear, watery plasma); sanguineous (bloody); serosanguineous (plasma and red blood); purulent (thick, odorous, possibly yellow, green, or brown)
Odor defines the presence or absence of high bacteria counts in the ulcer and should be assessed only after cleaning the wound. Almost all drainage has an odor. A strong or foul odor from the wound bed suggests infection. A mild odor may be due to the particular wound care products in use.
DESCRIPTION OF THE PERIWOUND SKIN
- Color: There may be redness, pallor, blanchable erythema, nonblanchable erythema, or purple discoloration.
- Temperature: Warmth may indicate further tissue breakdown or underlying infection.
- Induration: Abnormal firmness with a definite margin may indicate infection.
- Maceration: Softening of tissues may be due to soaking from wound drainage or contact with urine and/or stool.
- Denuded: Superficial skin loss may be due to drainage or trauma (such as from tape). Excoriation refers to linear scratch-like marks, not to skin loss from trauma or incontinence.
TYPE OF TISSUE EXPOSED (APPEARANCE OF WOUND BED)
- Red: May indicate clean, healthy granulation tissue. Granulation is a pink or red moist tissue composed of new blood vessels and connective tissue that fills an open wound when it starts to heal. It usually has an irregular, granular surface, like velvet. Not all red tissue is granulation.
- Yellow: May indicate the presence of drainage or slough. Slough is a soft, moist, avascular (lacking blood supply) tissue that may be yellow, white, tan, or green. It may be loosely or firmly attached. Sometimes resembles chicken fat.
- Black: May indicate the presence of eschar or necrotic tissue, which slows healing and allows bacteria to grow. It may be brown or tan and can be hard or soft or loosely or firmly attached. It can resemble a scab, but there is no healing occurring under it.
Always use a single-use, metric tape measure. Never measure using “coins” (dime-sized, quarter-sized, etc.). Measurements should be done at least weekly.
- Length: Linear distances from wound edge to wound edge. To measure consistently, look at the wound as if it were a clock face: the top of the wound (12 o’clock) is toward the patient’s head. The bottom of the wound (6 o’clock) is toward the patient’s feet. Length is the longest distance measured from 12 to 6 o’clock.
- Width: Width is longest distance measured from side to side, or from 9 to 3 o’clock.
- Depth: The distance from the visible surface to the deepest point in the wound base. Measure depth using a cotton-tip applicator, holding it perpendicular to the wound edge, placing the finger at the point on the swab that corresponds to the wound edge. While still holding this measurement, remove the swab and measure it on the tape measure.
- Undermining: Use a cotton-tip applicator to probe to the deepest part of the undermining. Mark the depth between the end of the applicator and the wound edge with the finger and measure it against the tape measure. Describe the location of the undermining using the clock face (e.g., “undermining extends from 12 o’clock to 5 o’clock and is deepest at 3 o’clock at 3 cm”).
- Tunneling or sinus tract: Measure the tract as for undermining and describe its location using the clock face.
Wound care documentation includes a variety of information that reflects the wound status while it heals. Providing an accurate description of the skin and wound characteristics is critical following each dressing change. These findings of the ulcer’s current status will help the clinician in revising the plan of care and treatment strategies over time.
After a few weeks of appropriate treatment, Mrs. Olivera, a patient with a pressure ulcer, remains in the hospital. The nurse manager reviews the nursing documentation, specifically the patient’s weekly wound measurements, for evidence that the wound is healing. The nurse manager detects a large variance between the patient’s wound measurements. On admission, Mrs. Olivera’s wound measured 4 cm x 6 cm x 3 cm (length x width x depth). A week later, the patient’s wound was documented to measure 1.5 x 2.5 x 1, indicating the wound had decreased in size dramatically. The third week the wound was documented as 5.5 x 3.5 x 2.5, indicating that the wound had worsened dramatically.
Such changes don’t seem to make sense to the nurse manager. In questioning the staff about these measurement differences, the nurse manager discovers that for the second week’s measurements, the nurse reversed the measuring device and measured in inches rather than centimeters. For the third week, another nurse documented the width as the length and the length as the width.
At the next staff meeting, the nurse manager brings a wound model so that the nurses can practice wound measurement. The manager reviews that length is a head-to-toe or 12 o’clock–to–6 o’clock measurement, and that width is a side-to-side or 9 o’clock–to–3 o’clock measurement. She also emphasizes the need to use metric measurements. As a result, Mrs. Olivera’s wound is now consistently measured, demonstrating that the facility’s care of the patient is helping to heal the wound.
Minimizing the Recurrence of Ulcers
Achieving a closed wound is just the beginning of the struggle to prevent an ulcer from recurring. Clinicians must emphasize and re-emphasize to patients and caregivers that measures to promote healing and prevent recurrence are lifelong. Recurrence rates for adults have been reported as high as 56%, and 21% develop a new ulcer at a different site (WOCN, 2010). The most common factors associated with recurrence are related to a lack of compliance with offloading the pressure area and maintaining a healthy lifestyle, such as stopping smoking, maintaining a normal weight, and controlling blood sugars if diabetic. Patient education regarding these factors is critical.
AVOIDABLE VERSUS UNAVOIDABLE PRESSURE ULCERS
Pressure ulcers are a global health concern because, for the most part, they are a costly, preventable complication. But are all pressure ulcers preventable or avoidable? In the past, clinicians have argued that pressure ulcers are not avoidable when the patient is too sick to be turned; when there are more vital organs to worry about than the skin; or when it is too difficult, expensive, or there is not enough staff to implement all preventative measures.
Yet as early as 2000, the U.S. Department of Health and Human Services stated that reducing pressure ulcer incidence is an objective for all healthcare providers. In 2008, the Center for Medicare and Medicaid Services (CMS) determined that hospital-acquired conditions could be reasonably prevented with evidence-based guidelines. In support of this determination, CMS stopped reimbursing hospitals for the treatment and care of pressure ulcers that were not present on admission.
Since then, it has been recognized that for some patients a pressure ulcer may be unavoidable. The definition of an unavoidable pressure ulcer is one that develops in spite of the facility’s best efforts at prevention. The difference between avoidable and unavoidable pressure ulcers is based on whether or not the treating facility was responsible in overseeing the provision of these actions:
- Evaluating the patient’s clinical condition and pressure ulcer risk factors
- Defining and implementing interventions consistent with the patient’s needs and goals and with recognized standards of practice
- Monitoring and evaluating the impact of the interventions
- Revising the interventions as appropriate
Thus, the topics discussed in this course—risk assessment, prevention, management, reevaluation, and documentation—are the very factors used to determine if all that can be done for the patient has in fact been done to prevent a pressure ulcer.
Pressure ulcers are alterations in skin integrity due to unrelieved pressure. Nearly all are considered preventable, and this requires a full commitment by the healthcare facility and staff so that a pressure ulcer will not occur.
There are many factors that contribute to the formation of a pressure ulcer, including comorbidities, incontinence, poor nutrition, and advanced age, but the most significant risk factor is immobility. Patients who are dependent on others for repositioning are at greatest risk of developing a pressure ulcer, for nonhealing of an ulcer should it occur, and for the recurrence of an ulcer.
Improving the mobility of patients, or mitigating the effects of immobility, requires the assistance of many in the healthcare team:
- The physical therapist, who teaches the patient, family, and staff how best to safely mobilize the patient
- The medical equipment department, that determines what equipment is available for the patient
- The social worker, who uncovers what resources are available to the patient
- Most of all, the bedside clinicians, whose role it is to assess all of the risk factors, to see that needed interventions are provided, and to reassess outcomes frequently.
To do less puts all vulnerable patients in jeopardy.
(Pressure ulcer risk assessment tool)
(Debridement of necrotic wounds)
Norton Scale (PDF)
(Pressure ulcer risk assessment tool)
Pressure Ulcer Scale for Healing (PDF)
(Pressure ulcer assessment and monitoring tool)
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course (view/download PDF from the menu at the top of this page).
Braden B. (2012). The Braden scale for predicting pressure sore risk: reflections after 25 years. Advances in Skin & Wound Care, 25(2), 61–3.
Bryant R & Nix D. (2012). Acute and chronic wounds: current management concepts (4th ed.). St. Louis: Mosby.
Bye K, Buescher D, Sandrick M. (2012). Never say never: a descriptive study of hospital-acquired pressure ulcers in a hospital setting. Journal of Wound, Ostomy, and Continence Nursing, 39(3), 274–81.
European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (EPUAP/NPUAP). (2009). Assessment and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel.
Gray M, Beeckman D, Bliss DZ, Fader M, Logan S, Junkin J, Doughty D, Kurz P. (2012). Incontinence-associated dermatitis: a comprehensive review and update. Journal of Wound, Ostomy, & Continence Nursing, 39(1), 61–74.
Hess C. (2013). Wound care (7th ed.). Philadelphia: Lippincott Williams & Wilkins.
Institute for Healthcare Improvement (IHI). (2007). Relieve the pressure and reduce harm. Cambridge, MA: IHI.
Joint Commission. (2013). Long term care: 2013 national patient safety. Retrieved from http://www.jointcommission.org
Kelechi T, Arndt J, Dove A. (2013). Review of pressure ulcer risk assessment scales. Journal of Wound, Ostomy, & Continence Nursing, 40(3), 232–6.
Lyder C & Ayello E. (2012). Pressure ulcer care and public policy: exploring the past to inform the future. Advances in Skin & Wound Care, 25(2), 72–6.
National Pressure Ulcer Advisory Panel (NPUAP). (2010). Position statement on reverse staging. Retrieved from http://www.npuap.org
Palmer M. (1996). Incontinence: a major problem for patients, a major concern for OBRA. Nursing Home Medicine, 4(9), 260–7.
Reichenbach V. (1996a). Incontinence. Gerontology Special Interest Section Quarterly Newsletter, 21, 1–3.
Reichenbach V. (1998b). From secrecy to self-esteem: addressing incontinence can restore dignity and independence to clients. OT Practice, 3, 26–9, 32.
Stillman R. (2010). Wound care. Retrieved from http://www.eMedicine.com
Wound, Ostomy, and Continence Nurses Society (WOCN). (2010). Guideline for prevention and management of pressure ulcers. Mt. Laurel, NJ: Author.