Transcript Clinical Practice Guideline (CPG) for Pressure Ulcers

Clinical Practice Guideline
(CPG) for Pressure Ulcers
For Practitioners
What is a Pressure Ulcer?
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Definition: A pressure ulcer is a localized
injury to the skin or underlying tissue, usually
over a bony prominence, that is a result of
pressure or of pressure combined with shear
or friction.
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Reported prevalence rates have ranged
from 2.3 percent to 28 percent and
reported incidence rates from 2.2 percent
to 23.9 percent
What is a Pressure Ulcer?
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95% of pressure ulcers develop on the lower body
(about 65% in the pelvic area and 30% in the
lower extremities)
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2-6 times greater mortality risk
Effective pressure ulcer treatment best
achieved through interdisciplinary team
approach
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Guidelines for Pressure Ulcers
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Recognition
Diagnosis
Prevention and Treatment
Monitoring
Recognition Steps
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Examine the patient’s skin thoroughly to
identify existing pressure ulcers
Identify risk factors for developing pressure
ulcers
Review records/resident interview to identify
previous history of pressure ulcers
Distinguishing Features of
Common Types of Ulcers
Ulcer Type
Pathophysiology
Location
Diabetic
Peripheral neuropathy secondary to
small or large vessel disease in
chronic, uncontrolled diabetes
Usually lower extremities
Ischemic
Reduction in blood flow to tissues
caused by coronary artery
disease, diabetes mellitus,
hypertension, hyperlipidemia,
peripheral arterial disease, or
smoking
Usually distal lower extremities
Tips of toes
Pressure
Unrelieved pressure resulting in
damage to skin or underlying
tissue
Usually over bony prominences (e.g.,
buttocks, elbows, heels, ischium,
medial and lateral malleolus,
sacrum, trochanters)
Venous
Venous hypertension resulting from
incompetence of venous valves, postphlebitic syndrome, or venous
insufficiency. Tend to be
irregularly shaped
Usually lower leg region
F314 Surveyor Guidance: Risk
Factors for Developing Pressure
Ulcers
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According to the surveyor guidance accompanying F314, the risk factors
that increase a patient’s susceptibility to developing pressure ulcers, or that
may impair the healing of an existing pressure ulcer, include but are not
limited to the following:
Comorbid conditions (e.g., diabetes mellitus, end-stage renal disease,
thyroid disease)
Drugs that may affect ulcer healing (e.g., steroids)
Exposure of skin to urinary or fecal incontinence
History of a healed Stage III or IV pressure ulcer
Impaired diffuse or localized blood flow (e.g., generalized atherosclerosis,
lower-extremity arterial insufficiency)
F314 Surveyor Guidance: Risk
Factors for Developing Pressure
Ulcers
Impaired or decreased mobility and
functional ability
 Increase in friction or shear
 Moderate to severe cognitive impairment
 Resident refusal of some aspects of care
and treatment
 Undernutrition, malnutrition, and hydration
deficits
(Adapted from CMS, 2007)
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Assessment
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Assess the patient’s overall physical and
psychosocial health and characterize the
pressure ulcer
Identify factors that can affect ulcer treatment
and healing
Identify priorities in managing the ulcer and
the patient
Assessment
A pressure ulcer should be assessed in the context of
the patient’s overall clinical, functional, and cognitive
status.
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Assess the status of each of the patient’s current
medical conditions.
Assess the patient’s nutritional status, including
dietary and fluid intake
Assess for the presence of medical conditions
that may interfere with independent feeding or
decrease overall oral intake
Assessment
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In patients with lower-extremity ulcers, assess for
the presence of coolness, delayed capillary refill,
dusky discoloration, or pedal pulses. The anklebrachial index, determined by Doppler arterial
studies, may be helpful in determining whether a
lower-extremity ulcer is caused by vascular
insufficiency or by pressure.
Assess the patient’s bed and chair mobility and
ability to sense and react to pain and discomfort.
Other Factors That Should Be
Assessed in a Patient With a
Pressure Ulcer
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Comorbid conditions (e.g., anemia, congestive heart
failure, diabetes, edema*, immune deficiency,
malignancies, peripheral vascular disease, thyroid
disease)
Complications (e.g., cellulitis, osteomyelitis)
Pain
Presence of:
Contractures
Dementia
Depression
Terminal illness
Staging of pressure ulcers
Suspected deep tissue injury
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Purple or maroon localized area of discolored intact skin or blood-filled blister
due to damage of 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.
Further description: Deep tissue injury may be difficult to detect in individuals
with dark skin tones. Evolution may include a thin blister over a dark ulcer bed.
The ulcer may further evolve and become covered by thin eschar*. Evolution
may be rapid, exposing additional layers of tissue even with optimal treatment.
Stage I
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.
Further description: The area may be painful, firm, soft, warmer or cooler as
compared to adjacent tissue. Stage I may be difficult to detect in individuals
with dark skin tones. May indicate “at risk” persons (a heralding sign of risk).
Staging of pressure ulcers
Stage II
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Partial thickness loss of dermis presenting as a shallow open
ulcer with a red pink ulcer bed, without slough*. May also
present as an intact or open/ruptured serum-filled blister.
Further description: Presents as a shiny or dry shallow ulcer
without slough or bruising. This stage should not be used to
describe skin tears, tape burns, perineal dermatitis,
maceration* or excoriation.
Bruising indicates suspected deep tissue injury
Staging of pressure ulcers
Stage III
 Full thickness tissue loss. Subcutaneous fat may be visible but bone,
tendon or muscle are not exposed. Slough may be present but does not
obscure the depth of tissue loss. May include undermining* and
tunneling*.
Further description: 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 can be shallow. In
contrast, areas of significant adiposity can develop extremely deep
Stage III pressure ulcers.
Bone/tendon is not visible or directly palpable.
Staging of pressure ulcers
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Stage IV
Full thickness tissue loss with exposed bone, tendon or
muscle. Slough or eschar may be present on some parts
of the ulcer bed. Often include undermining and
tunneling.
Further description: The depth of a Stage 4 pressure
ulcer varies by anatomical location. The bridge of the
nose, ear, occiput and malleolus do not have
subcutaneous tissue and these ulcers can be shallow.
Stage 4 ulcers can extend into muscle and/or supporting
structures (e.g., fascia, tendon or joint capsule)
making osteomyelitis possible. Exposed bone/tendon is
visible or directly palpable.
Staging of pressure ulcers
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Unstageable
Full thickness tissue loss in which the base of the
ulcer is covered by slough (yellow, tan, gray, green
or brown) and/or eschar (tan, brown or black) in the
ulcer bed.
Further description: Until enough slough and/or
eschar is removed to expose the base of the ulcer,
the true depth, and therefore stage, cannot be
determined. Stable (dry, adherent, intact without
erythema* or fluctuance*) eschar on the heels
serves as “the body’s natural (biological) cover” and
should not be removed.
National Pressure Ulcer Advisory Panel, 2007
Factors that can affect ulcer
treatment and healing
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Physiologic factors
Functional factors
Psychosocial factors
Ethical considerations
Identify Priorities in managing
the ulcer and the patient
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Effective management of a pressure ulcer requires:
Identification and treatment of causative factors when feasible,
Identification and treatment of modifiable comorbid conditions,
Provision of optimal nutritional support,
Determination of the best topical care to facilitate ulcer healing,
Prevention and management of infection* of the ulcer or adjacent
tissue, and
Pain control related to the ulcer and any comorbid conditions.
Prevention and Treatment
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Pressure Ulcer Prevention Measures
Create a turning and positioning schedule that is based on the
patient’s individual risk factors
Do not massage reddened areas over bony prominences
Evaluate and manage urinary and fecal incontinence
Initiate a plan to prevent or manage a contracture
Inspect skin during bathing or daily personal care
Maintain adequate nutrition and hydration if possible
Maintain the lowest possible head elevation to reduce the impact
of shear
Position the patient to minimize pressure over bony prominences
and shearing forces over the heels and elbows, base of head, and
ears
Use appropriate offloading or pressure-redistribution devices
Use lifting devices such as draw sheets or a trapeze
Use proper transferring techniques
Unavoidable Pressure Ulcers
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Under the surveyor guidance accompanying
F314, an unavoidable pressure ulcer is a
pressure ulcer that develops even though a
facility has done the following:
Evaluated the patient’s clinical condition and risk
factors;
Defined and implemented interventions
consistent with patient needs, goals, and
recognized standards of practice;
Monitored and evaluated the impact of these
interventions; and
Revised the approaches as appropriate
Unavoidable Pressure Ulcers
The following clinical circumstances, among others,
may impede or prevent healing or result in additional
ulcer development that may be unavoidable:
 Cachexia,
 Metastatic cancer,
 Multiple organ failure,
 Sarcopenia,
 Severe vascular compromise, and
 Terminal illness.
Nutrition
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Increased protein intake is often emphasized in
patients with nonhealing wounds; adequate intake
of any single nutrient, however, does not prevent
pressure ulcer formation or facilitate healing.
Many clinicians recommend caloric intake of 30
kcal/kg to 35 kcal/kg33 and daily protein intake of
1.2 to 1.5 g/kg of body weight34 for nutritionally
compromised patients who have or are at risk of
pressure ulcers
Pain Management
Pain management. After assessing pain and
defining its characteristics (e.g., frequency,
intensity, possible aggravating factors) and
causes, treat it aggressively by using
appropriate pain management protocols.
(See AMDA’s 2003 clinical practice guideline,
Pain Management in the Long-Term Care
Setting
Turning and Positioning
Proper positioning, turning, and transferring
techniques are important to manage pressure
and shearing forces, ensure weight
redistribution on support surfaces, and
protect uninvolved skin. Evidence does not
support any specific time interval for turning
patients as a preventive or healing strategy
for pressure ulcers
Manage Pressure
A systematic review of support surfaces for pressure
ulcer prevention found that the use of ordinary foam
mattresses (less than 4 inches thick) presented a
higher risk of pressure ulcer development than the
use of higher-specification mattresses.45 Patients at
risk of skin breakdown should be placed on a static
support surface (e.g., foam overlay, foam mattress,
static flotation device) rather than on a standard
mattress.
Necrotic Tissue
Pressure ulcer healing may be delayed by the
presence of necrotic tissue, which also
provides a medium for bacterial growth. Any
necrotic tissue observed during assessment
of the ulcer should be debrided, provided that
this intervention is consistent with overall
patient care goals.
Debridement of an ulcer
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When choosing a debridement method, consider
Ulcer size,
Amount of slough and exudate,
Presence and severity of pain associated either with the ulcer or
with the method of debridement,
Feasibility of performing sharp or surgical debridement, and
Risks of transporting the patient outside of the facility vs. the
benefits of surgical debridement.
Heel Ulcers
It is generally recommended not to debride
heel ulcers with dry, hard eschar unless there
is edema, erythema, fluctuance, or drainage.
Monitor heel ulcers closely for evidence of
infection, at which time debridement should
occur.
Cleaning the wound
An effective antiseptic should:
 Act quickly;
 Be nonirritating;
 Be nontoxic to viable tissue;
 Have a broad spectrum of activity;
 Have low resistance potential; and
 Work in the presence of blood, fibrin, pus, and
slough
Ulcer Dressings
The goals of dressing an ulcer are to:
 Keep the ulcer bed moist and the surrounding
skin dry,
 Protect the ulcer from contamination, and
 Promote healing.
Factors to Consider When
Selecting Ulcer Care Products
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Burden to patient (i.e., number of daily dressing
changes required)
Cost-effectiveness of product
Costs of ancillary supplies and equipment
associated with treatment
Ease of use and cost of staff time to use the product
Safety, efficacy, and likelihood and potential severity
of complications
Ulcer characteristics (e.g., depth, condition of
surrounding skin, location near sources of
contamination, presence and amount of exudate)
F314 Surveyor Guidance:
Monitoring Considerations
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Daily Monitoring
Evaluate ulcer if no dressing is present
Evaluate status of dressing if present: Is dressing
intact? Is drainage present? If so, is it leaking?
Status of area surrounding ulcer that can be
observed without removing the dressing
Presence of possible complications (e.g., signs of
increasing area of ulceration, soft tissue infection)
Evaluate whether pain, if present, is adequately
controlled
Document when a change or complication is
identified
F314 Surveyor Guidance:
Monitoring Considerations
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Weekly or Dressing Change Monitoring
Location and staging of ulcer
Size (perpendicular measurement of greatest extent of length and width
of ulceration); depth; and presence, location, and extent of
undermining, tunneling, or sinus tract*
Presence of exudate; if present, type (e.g., purulent, serous), color,
odor, approximate amount
Presence of pain; if present, nature and frequency (e.g., episodic,
continuous)
Status of wound bed: color and type of tissue; evidence of healing (e.g.,
granulation tissue); necrosis (slough, eschar)
Description of wound edges and surrounding tissue (e.g., rolled edges,
redness, hardness/induration, maceration)
F314 Surveyor Guidance:
Monitoring Considerations
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Use of Photography in Pressure Ulcer Monitoring
Photography may be used in monitoring as part of the facility’s
compliance efforts, if the facility has developed a protocol consistent
with accepted standards, which include the following:
Frequency of use
Photos taken at a consistent distance from the wound
Type of photographic equipment used
Means to ensure that digital images are accurate and not modified
Inclusion of resident identification, ulcer location, dates, etc., within the
photographic image
Parameters for comparison over time
IMPORTANT!
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It is important to establish goals consistent with
the values and lifestyle of the individual and
his/her family.