Transcript pressure ulcer

PRESSURE
ULCERS
Kansas Reynolds Program in Aging
Shelley B. Bhattacharya, D.O., M.P.H.
Assistant Professor, Director of Geriatric Education
Department of Family Medicine
OBJECTIVES
Know and understand:

The morbidity and mortality associated with pressure
ulcers for older adults

The common risk factors for pressure ulcer development

Evidence based techniques for preventing pressure
ulcers

The pressure ulcer staging system and treatment
strategies for each stage
ACOVE INDICATOR
Concerning the pressure ulcer care of an older adult :
 If a vulnerable older adult is admitted to an intensive
care unit or a medical or surgical unit of a hospital and
cannot reposition himself or herself or has limited
ability to do so, THEN risk assessment for pressure
ulcers should be performed on admission
 If a vulnerable older adult is identified as at risk for
pressure ulcer development or a pressure ulcer risk
assessment score indicates that the person is at risk,
THEN preventive intervention must be instituted within
12 hours, addressing repositioning needs and
pressure reduction (or management of tissue loads)
ACOVE INDICATOR


If a vulnerable older adult presents with a
pressure ulcer, THEN the pressure ulcer should
be assessed for 1) location, 2) depth and stage,
3) size and 4) presence of necrotic tissue
If a vulnerable older adult is identified as at risk for
pressure ulcer development and has malnutrition
(involuntary weight loss >10% over 1 year or low
albumin or prealbumin levels), THEN nutritional
intervention or dietary consultation should be
instituted
TOPICS COVERED

Epidemiology

Complications

Risk Factors and Risk Assessment

Evidence based review of prevention techniques

Ulcer Assessment and 2007 Staging definitions

Monitoring and Treatment
PRESSURE ULCER: DEFINITION
 Definition
(2007 National Pressure Ulcer
Advisory Panel): an injury caused by
unrelieved pressure on a specific region
of skin and muscle in bed or chair bound
patients
 The
time for pressure ulcer
development is variable due to severity
of illness and a number of comorbid
conditions
PRESSURE ULCERS: A MAJOR ISSUE
IN GERIATRIC MEDICINE

Affects 1 million adults annually

Higher risk in older persons because:
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Local blood supply to skin decreases
Epithelial layers flatten and thin
Subcutaneous fat decreases
Collagen fibers lose elasticity
Tolerance to hypoxia decreases
1 of 3 sentinel events for long-term care
Pressure Ulcer Staging
Source: http://www.medicaledu.com/staging.htm
STAGING OF PRESSURE ULCERS
Stage I: Persistent nonblanchable
erythema of intact skin. In darker skin tones,
ulcer may appear with persistent red, blue,
or purple tones. Most common of all
pressure ulcers. “At risk” person.
Used with permission EPUAP
STAGING OF PRESSURE ULCERS

Stage II: Partial-thickness skin loss
involving epidermis, dermis, or both. Ulcer
is superficial and presents as an abrasion,
blister, or shallow crater.
Pressure ulcer over
the left ischial
tuberosity is
shallow with loss of
dermis.
Used with permission LWW
STAGING OF PRESSURE ULCERS
Stage III: Full-thickness skin loss involving
damage or necrosis of subcutaneous
tissue that may extend down to, but not
through, underlying fascia.
The right
sacral ulcer
extends into
subcutaneous
tissue.
No muscle,
bone, or
tendon is
visible.
Used with permission LWW
STAGING OF PRESSURE ULCERS

Stage IV: Full-thickness skin loss with
extensive destruction, tissue necrosis, or
damage to muscle, bone, or supporting
structures (e.g. tendon, joint capsule).
Undermining and sinus tracts may also be
present.
Used with permission LWW
STAGING OF PRESSURE ULCERS

Unstageable: Full thickness tissue loss in
which slough (yellow, tan, gray, green or
brown), eschar (tan, brown or black), or
both in the wound bed cover the base of
the ulcer.
Pictures - Royal College of Surgeons of Edinburgh
PREVALENCE OF PRESSURE ULCERS
VARIES BY SETTING
35
1% to 30%
3% to 30%
30
25
5% to 15%
20
15
10
5
0
Hospital
Home Care
Nursing Home
Source: GRS 6
PREVALENCE OF PRESSURE ULCERS
VARIES BY STAGE
Stages III
& IV, 20%
Stage I,
47%
Stage II,
33%
Source: GRS 6
RISK FACTORS

Older adults have a much higher likelihood of developing
pressure ulcers due to their risk factors

Intrinsic risk factors are physiologic factors or disease
states that increase the risk for pressure ulcer
development

Extrinsic risk factors are external factors that damage
skin
INTRINSIC FACTORS PREDICTIVE OF
PRESSURE ULCER DEVELOPMENT
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Age 70+
Impaired mobility
Current smoking
Low BMI
Confusion
Urinary and fecal
incontinence
Malnutrition
Restraints

Comorbid conditions:
malignancy, diabetes,
stroke, pneumonia,
CHF, fever, sepsis,
hypotension, renal
failure, dry skin, history
of pressure ulcers,
anemia, lymphopenia,
hypoalbuminemia
EXTRINSIC FACTORS PREDICTIVE OF
PRESSURE ULCER DEVELOPMENT
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Alcohol/drug abuse,
Friction/shear/pressure
Inadequate current wound care
Immunosuppressive and chemotherapeutic
agents
Nutritional deficiency
Uncontrolled excess local pressure
Adverse reactions to skin care products
Smoking
Fecal and urinary incontinence
Usual pressure ulcer locations

Over Bony Prominences
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Occiput
Ears
Scapula
Spinous Processes
Shoulder
Elbow
Iliac Crest
Sacrum/Coccyx
Ischial Tuberosity
Trochanter
Knee
Malleolus
Heel
Toes
Source: http://www.nursingquality.org/NDNQIPressureUlcerTraining/module1/staging05.aspx
Other locations…

Any skin surface subject to excess pressure
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Examples include skin surfaces under:

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Oxygen tubing
Urinary catheter drainage tubing
Casts
Cervical collars
POSSIBLE COMPLICATIONS

Sepsis (aerobic or anaerobic bacteremia)
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Localized infection, cellulitis, osteomyelitis

Pain
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Depression
Mortality rate = 60% in older persons who
develop a pressure ulcer within 1 year of hospital
discharge
RISK ASSESSMENT INSTRUMENTS
Widely used tools for identifying older patients at risk for
developing ulcers: SCREENING TOOLS

Norton scale:
sensitivity =73%–92%, specificity = 61%–94%

Braden scale:
sensitivity = 83%–100%, specificity = 64%–77%
Both recommended by Agency for Healthcare Research
and Quality
BRADEN SCALE
Provides method for assessing a patient’s pressure ulcer risk
by evaluating:

Sensory perception: ability to respond to pressurerelated discomfort

Moisture: degree to which skin is exposed to
moisture

Activity: degree of physical activity

Mobility: ability to change and control body position

Nutrition: usual food intake

Friction and Shear
NORTON SCALE
Provides method for assessing a patient’s pressure
ulcer risk by evaluating:


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Physical condition
Mental condition
Level of physical activity
Mobility
Continence or incontinence
Scale Documentation Frequency

October 2007 JAGS article recommends
using the scales:
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If in hospital setting: on admission, if at risk then
q 48 hours thereafter;
If in skilled nursing facility: on admission, q wk for
1st 4 weeks, then q 3mos thereafter;
If in home health program: on admission, if found
to be at risk, then q wk for 4 weeks and every
other week thereafter.
PREVENTION
An evidence-based approach to preventing
pressure ulcers focuses on:
Skin care
Mechanical loading
Support surfaces
PREVENTION: SKIN CARE

Daily systematic skin inspection and cleansing

 factors that promote dryness

Avoid massaging over bony prominences

 moisture (incontinence, perspiration, drainage)

Minimize friction and shear
PREVENTION:
MECHANICAL LOADING

Reposition at least every 2 hours (may use pillows, foam
wedges)

Keep head of bed at lowest elevation possible

Use lifting devices to decrease friction and shear

Remind patients in chairs to shift weight every 15 min
“Doughnut” seat cushions are contraindicated,
may cause pressure ulcers

Pay special attention to heels (heel ulcers account for 20%
of all pressure ulcers)
PREVENTING HEEL ULCERS

Assess heels of high-risk patients every day
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Use moisturizer on heels (no massage) twice
a day
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Apply dressings to heels:
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Transparent film for patients prone to friction
problems
Single or extra-thick hydrocolloid dressing for
those with pre-stage 1 reactive hyperemia
PREVENTING HEEL ULCERS

Have patients wear:
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Socks to prevent friction (remove at bedtime)
Properly fitting sneakers or shoes when in wheelchair
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Place pillow under legs to support heels off bed
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Place heel cushions to prevent pressure
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Turn patients every 2 hours, repositioning heels
PRESSURE-REDUCING
SUPPORT SURFACES
**Use for all older persons at risk for ulcers**
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Static
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Foam, static air, gel, water, combination (less expensive)
Dynamic
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Alternating air, low-air-loss, or air-fluidized
Use if the status surface is compressed to <1 inch or high-risk
patient has reactive hyperemia on a bony prominence despite
use of static support
Potential adverse effects: dehydration, sensory deprivation,
loss of muscle strength, difficulty with mobilization
SUPPORT SURFACES

Moist

Heat

Shear

Pressure
$
no
no
no
yes
Static: flotation $
no
no
yes
yes
Dynamic:
air-fluidized
yes
yes
yes
yes
yes
yes
?
yes
no
no
yes
yes
Surface
Static: foam
Dynamic:
low-air-loss
Dynamic:
alternating air
$$$
$$$
$$
MANAGEMENT:
GENERAL ASSESSMENT
Identify and effectively manage issues that have
placed patient at risk for pressure ulcers:

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


Medical diseases
Health problems (eg, urinary incontinence)
Nutritional status
Pain level
Psychosocial health
MANAGEMENT:
ULCER ASSESSMENT
Evaluate and document the following:
Location
 Stage
 Area
 Depth
 Pain

Drainage
 Necrosis
 Granulation
 Cellulitis

MANAGEMENT:
MONITORING HEALING
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Document all observations over time
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Describe each ulcer to track progress of healing
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Do not use “reverse staging”
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Ulcers are filled with granulation tissue (endothelial cells,
fibroblasts, collagen, extracellular matrix)
Ulcers do not replace lost muscle, subcutaneous fat, or dermis
before re-epithelializing
E.g. Stage IV cannot become stage III
Use validated tools (eg, PUSH, see next slide)
PRESSURE ULCER SCALE
FOR HEALING (PUSH)
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A validated method to document healing over time
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Observe and measure the ulcer’s:
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Surface area: measure with centimeter ruler
Exudate: estimate portion of ulcer bed covered by drainage
Appearance: estimate portion of ulcer for each tissue type
(epithelial, granulation, slough, necrotic)
Assign weighted score to obtain total score; total
scores over time indicate healing or deterioration
Evidence for Wound Assessments

No direct evidence that wound
assessments improve clinical outcomes,
but has been found that identifying wound
characteristics can predict time to healing

Adequate assessment guides treatment,
provides data for comparison and can help
predict time to healing
MANAGEMENT:
CONTROL OF INFECTIONS

Wound cleansing and dressing are the key

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 frequency when purulent or foul-smelling drainage is first
observed
Avoid topical antiseptics because of their tissue toxicity
With failure to heal or persistent exudate after 2
weeks of optimal cleansing, consider trial of topical
antibiotics
TOPICAL AGENT
Strep
Pseudomonas
x*
x
x
x
x
x
Mupiricin 2%
cream/ointment
x*
x
Polymyxin B sulfate
x*
x
x
x
x
x
x*
x*
x
x
x
x
Iodine (Iodosorb)
Gentamycin sulfate
cream/ointment
S. Aureus
Metronidazole
gel/cream – works
against anaerobes
Polymyxin B sulfate,
Bacitracin zinc,
Neomycin
Silver sulfadiazine
Ionized Silver
MANAGEMENT:
CONTROL OF INFECTIONS
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If still no healing, consider presence of:
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Cellulitis-
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or Osteomyelitis—
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Biopsy for culture of underlying tissue, bone
May need systemic antibiotics
Staphylococcus aureus is by far the most commonly involved
X-Ray—Soft tissue swelling, bone destruction (10-21 d after
infection)
CT—Medullary and cortical destruction
MRI—Better for soft tissue assessment, good for early bony edema
Remember, the white-blood-cell count is not a reliable indicator
and can be normal even when infection is present.
MRI views of osteomyelitis
Courtesy: Lancet 2004 Jul 24;364(9431):369
Bacterial Culture Collection
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Bacterial culture: IF have nonhealing
wounds, increased discharge or develop a
new odor
Done selectively only IF suspect deep tissue
infection
Take from cleaned wound margin
Swab healthy-appearing granulation tissue
by rotating the swab in a zigzag pattern
MANAGEMENT:
METHODS OF DEBRIDEMENT
Type
Methods
Comments
Mechanical
Wet-to-dry irrigation,
hydrotherapy
May remove both dead &
live tissue; may be painful
Surgical, sharp
Scalpel, scissor to remove Quick, effective; use for
dead tissue; laser
infection; pain
debridement
management needed
Enzymatic
(Accuzyme)
Topical agent to dissolve
dead tissue
Use if no infection; may
damage skin
Autolytic
(Duoderm)
Allows dead tissue to selfdigest
Biosurgery
Larvae to digest dead
tissue
Use if other methods not
tolerated & no infection;
effect delayed
Quick, effective, good if
surgical debridement not
an option
MANAGEMENT:
DRESSINGS
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Transparent film (Tegaderm): stage I, protects from friction
Contraindicated: skin tears, draining, suspected infection
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Foam island: stages II, III
Contraindicated: excessive exudate; dry, crusted wound
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Hydrocolloid (Duoderm): stages II, III
Contraindicated: poor skin integrity, infection, wound needs
packing

Petroleum-based nonadherent: stages II, III, graft sites
MANAGEMENT:
DRESSINGS
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Calcium Alginate (Tegaderm HI): stages II, III, IV, for excessive
drainage
Contraindicated in: dry or superficial wound with maceration

Hydrogel, amorphous (Curasol): stages II, III, IV; must combine
with gauze dressing
Contraindicated: maceration, excess exudate

Hydrogel, sheet (Nu-Gel): stage II, skin tears
Contraindicated: maceration, moderate to heavy exudate

Gauze packing: stages III, IV, deep wounds
MANAGEMENT:
NUTRITION

If an older adult at risk for pressure ulcers has
malnutrition, a nutritional assessment must be
done

Markers of poor dietary and protein intake, low
albumin and weight, are associated with poor
pressure ulcer development and healing
Nutrition and Ulcers—the evidence!
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No causal relationship found between
malnutrition and pressure ulcer development
Weak evidence for nutritional support that
achieves 30 to 35 calories/kg/day and 1.25 to
1.5 g of protein/kg/day to heal pressure ulcers
Weak evidence for supplemental vitamins and
minerals for pressure ulcer prophylaxis
MANAGEMENT:
SURGICAL REPAIR
May be used for stage III and IV ulcers
Direct closure, skin grafting, skin flaps, musculocutaneous
flaps, free flaps
Risks and benefits of surgery must be carefully
weighed for each patient:
•
Many stage III and IV ulcers heal over a long time with local
wound care
•
Rate of recurrence of surgically closed pressure ulcers is high
MANAGEMENT:
ADJUNCTIVE THERAPIES

No data to support low-energy laser irradiation,
therapeutic ultrasound
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Promising research continues:
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Recombinant platelet-derived growth factors
Electrical stimulation
Vacuum-assisted closures
Warm-up therapy (  basal ulcer temperature promotes healing)
Hyperbaric oxygen
Technology
Description
Approved
Indications
Comments
Apligraf
Human skin equivalent
Resistant venous leg
ulcers, refractory
diabetic neuropathic
foot ulcers
Expensive; best for
wounds >1 year old; 5
day shelf-life
Dermagraft
Human skin equivalent
DM neuropathic foot
ulcers; venous ulcers
(pending)
Expensive; 6 month
shelf life (-70 degree
freezer)
Regranex
Recombinant PDGF in
a hydrogel
Full thickness DM
neuropathic foot ulcers
w/adequate blood
supply and no infection
Effectiveness limited by
fact that infxn may not
be clinically apparent;
not reimbursed by
Medicare
Platelet-Rich Plasma
(PRP)
Derived from pt’s blood;
activated w/thrombin;
gel form; apply
immediately after prep
Acute and chronic
wounds; may be
applied as part of a
surgical procedure
Left in place for 3-7
days; may require
repeat applications
usually every other
week
Oasis
Freeze-dried porcine
small intestine
submucosa
Acute and non-healing
wounds
Selective for patients
refractory to appropriate
wound care; easy use;
inexpensive; usually
reimbursed
Technology
Description
Approved
Indications
Comments
V.A.C.
Negative pressure in a
closed dressing system
Highly exudative wounds
Removes excess
interstitial fluid; can tx
multiple wound sites;
reduced frequency of
dressing changes
Mini-V.A.C.
Allows for ambulatory
activities
For small wounds
Facilitates ambulation an
ADLs
Warm-up
Heat-assisted occlusive
dressing
Resistant or painful
wounds
O2 transport enhanced
by local heat
Hyaluronic Acid
Ester of hyaluronic acid
Hard to heal wounds with
chronic inflammation
Easy use; inexpensive;
need bacterial balance
for optimal tx
Electrical Stimulation
High voltage electrical
stimulation
Pressure ulcers
Effective in non-healing
wounds?
Ultrasound
Mechanical vibration
Pressure ulcers
Effective in non-healing
wounds?
Hyperbaric oxygen
(HBO) therapy
Systemic delivery of O2
in chambers at 2-3 times
atmospheric pressure
while breathing 100% O2
Necrotizing soft tissue
infxn; gas gangrene;
refractory osteomyelitis;
thermal burns; radiation
damage; compromised
skin grafts and flaps
Expensive; specialized
training/equipment;
limited availability
SUMMARY

Older adults are at high risk for development of pressure
ulcers

Pressure ulcers may result in serious morbidity and
mortality

Techniques that reduce pressure, moisture, friction, and
shear can prevent pressure ulcers

Pressure ulcers should be treated with proper cleansing,
dressings, debridement, or surgery as indicated
References




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Geriatrics Review Syllabus, 6th edition, p259-268
Bates-Jensen, B et al. Quality Indicators for the care of pressure
ulcers in vulnerable elders; JAGS: 55:S409-S416, October 2007
AHCPR, Pressure Ulcers in Adults: Prediction and Prevention.
Rockville, MD: US Dept of Health and Human Services, Public
Health Service, Agency for Healthcare Policy and Research. May
1992
Fowler E, Krasner D, et al. Healing Environments for chronic
wound care: optimizing local wound management as a component
of holistic interdisciplinary patient care. Treatment of Chronic
Wounds: Number 11 in a series.
Krasner D, Margolis DJ, et al. Prevention and management of
pressure ulcers. Treatment of Chronic Wounds: Number 6 in a
series.
Patterson, BL. A Pictorial Guide to Pressure Ulcers. Consultant.
Feb 2006: 205-8.
References

http://www.nursingquality.org/NDNQIPressureUlcerTrain
ing/index2.htm


www.medicaledu.com - Wound Care Information Network
www.etrs.org – European Tissue Repair Society
www.woundsource.com

http://www.npuap.org/PDF/push3.pdf


Sussman C, Bates-Jensen BM. Wound Care: A Collaborative
Practice Manual for Physical Therapists and Nurses. 1st edition.
1998.
Ham et al, Primary Care Geriatrics, 3rd ed., p.431-439

Lancet 2004 Jul 24;364(9431):369
