Transcript Pressure Ulcer/Non-pressure Ulcer Follow-up Training

F314 Follow-up Clinical Training
January 23, 2006
Presented by
Jeri Lundgren, RN, CWS, CWCN
Wound Care Consultant
Pathway Health Services
1
Training Objectives
 Know what a comprehensive risk assessment
should include
 Discuss individualized turning and repositioning
 Understand the treatment for lower extremity
wounds
 Describe the causes of pressure ulcers
 Differentiate between pressure reduction verses
pressure relief
 Discuss the application of pulsatile lavage in
wound management
2
Risk Assessment
 Guidance states
“Although the requirements do not mandate
any specific assessment tool, other than
the RAI, validated instruments are
available to assess risk for developing
pressure ulcers”
3
Risk Assessment Tools
BRADEN SCALE






Mobility
Activity
Sensory Perception
Moisture
Friction & Shear
Nutrition
*Please note: Using the Braden scale requires obtaining permission at
www.bradenscale.com or (402) 551-8636
4
Risk Assessment Tools
 “Regardless of any resident’s total risk score,
the clinicians responsibility for the resident’s
care should review each risk factor and
potential cause(s) individually”
 “an overall risk score indicating the resident is
not at high risk of developing pressure ulcers
does not mean that existing risk factors or
causes should be considered less important or
addressed less vigorously than those factors or
causes in the resident whose overall score
indicates he or she is at a higher risk of
developing a pressure ulcer.”
5
Risk Assessment Tools
 A COMPREHENSIVE risk assessment
should be done:
– Upon admission
– *Weekly for the first four weeks
after admission*
– With a change of condition
– Quarterly
6
Comprehensive Risk
Assessment
 Overall skin condition - including tissue
tolerance
 Medical diagnosis and co-morbidities
 Medications or Treatments
 Degree of Mobility
 Incontinence of Bowel and/or Bladder
 Scarring over bony prominences
 Contractures
 Bedfast or Chair-bound
7
Comprehensive Risk
Assessment






Cognitively impaired
Resident choice
Restraints
Unrelieved pain
Slouching in a chair
Repeated hospitalizations or ER visits
with-in 6 months
 Nutrition and hydration
8
Comprehensive Risk
Assessment
 The overall goal of the risk assessment is
to ensure that individualized interventions
are attempted to stabilize, reduce or
remove the underlying risk factors
9
Prevention Interventions:
Provide appropriate pressure reduction or relief
10
Prevention Interventions
Choose appropriate pressure reducing
surfaces while in bed and sitting
 Pressure Reduction: Is the reduction of
interface pressure, not necessarily below
capillary closure pressure
 Pressure Relief: Is the reduction of interface
pressure below capillary closure pressure
Capillary closing pressure is also individual
to the resident
11
Support Surfaces
 There is no standardize testing or requirements
for support surfaces
 There is no set mandate or recommendation as
to when a specific type of support surface
should be used.
 Guidance states:
“Appropriate support surfaces or devices should be
chosen by matching a device’s potential therapeutic
benefit with the resident’s specific situation: for
example, multiple ulcers, limited turning surfaces
and ability to maintain position.”
12
Support Surfaces
 Surveyors should consider the following
pressure redistribution issues:
– Static devices (e.g., solid foam or gel
mattresses) may be indicated when a resident is
at risk or delayed healing. A specialized
reduction cushion or surface might be used to
extend the time a resident is sitting in a chair;
however, the cushion does not eliminate the
necessity for periodic repositioning
13
Support Surfaces
 pressure redistribution issues continued:
– Dynamic pressure reduction surfaces may be
helpful when:
» The resident can’t assume a variety of positions
without bearing weight on a pressure ulcer
» The resident completely compresses a static
device
» The pressure ulcer is not healing as expected,
and it is determined that pressure may be
contributing to the delay in healing
14
Prevention Interventions
15
Support Surfaces
 Use of recliners, guidance states
“The care plan for a resident who is reclining
and is dependent on staff for repositioning
should address position changes to maintain
the resident’s skin integrity.”…..”Elevating the
head of the bed or the back of a reclining chair
to or above a 30 degree angle creates
pressure comparable to that exerted while
sitting, and requires the same considerations
regarding repositioning as those for a
dependent resident who is seated.”
16
Support Surfaces
 Recliners continued
– Remember off-loading is one full minute
of pressure relief
– Is the turning schedule in the best
interest for the resident or per their
wishes or is it in the best interest for
staff
 Foam vs. Gel vs. Air wheelchair
cushions– Overall ensure it is the best
for the individual resident
17
Prevention Interventions
 Develop an INDIVIDUALIZED turning & repositioning
schedule
 Tissue tolerance is the ability of the skin and it’s
supporting structures to endure the effects of
pressure with out adverse effects
 There is no standard/mandated “Tissue Tolerance
Test”
 “A skin inspection should be done, which should
include an evaluation of the skin integrity and tissue
tolerance, after pressure to that area, has been
reduced or redistributed”
18
Prevention Interventions
 After skin integrity and tissue tolerance has
been assessed the resident then should be put
on an appropriate INDIVIDUALZED turning and
repositioning program
 Ongoing monitoring of tissue tolerance and skin
integrity should be done
 Recommend assessing skin integrity and tissue
tolerance upon admission and with a significant
change of condition
19
Lower Extremity Wounds
• Arterial Insufficiency
• Venous Insufficiency
• Peripheral Neuropathy/Diabetic
Referred to F309 Tag
20
Arterial Insufficiency
21
Arterial Insufficiency Ulcers
Location
– Toe tips and/or web spaces
– Phalangeal heads around lateral malleolus
– Areas exposed to pressure or repetitive
trauma (shoe, cast, brace, etc.)
22
Arterial Insufficiency
23
Arterial Insufficiency
Interventions
Measures to Improve Tissue Perfusion
– Revascularization if possible
– Lifestyle changes (no tobacco, no caffeine, no
constrictive garments, avoidance of cold)
– Hydration
– Measures to prevent trauma to tissues
(appropriate footwear at ALL times)
– Aspirin in doses of 75-325 mg oral/day
24
Arterial Insufficiency
Interventions
Nutrition
Consider niacin; niacin has been shown to 
HDL-C &  Triglycerides in oral dosages of
3,000mg/d
L-Arginine (vasodilator properties) oral intake
of 6.6 g/day for 2 weeks improved symptoms
of intermittent claudication
Provide nutritional support with 2,000 or more
calories preoperatively and postoperatively, if
possible; this has been benefited patients
undergoing amputations
25
Arterial Insufficiency
Interventions
Pain Management
Recommend walking to near maximal pain
three times per week.
Administer Cilostazol, 100mg BID, orally
Topical Therapy
Dry uninfected necrotic wound: KEEP DRY
Dry INFECTED wound: Immediate referral for
surgical debridement/aggressive antibiotic
therapy (Topical antibiotics are typically ineffective for arterial wounds)
26
Arterial Insufficiency
Interventions
Topical Therapy (continued)
Open Wounds
Moist wound healing
Non-occlusive dressings (e.g. solid hydrogel)
Aggressive treatment of any infection
Adjunctive Therapies
Hyperbaric oxygen therapy
Intermittent pneumatic compression
Topical autologous activated mononuclear
cells, twice per week (Autologel)
27
Arterial Insufficiency
Interventions
Adjunctive Therapies (continued)
High-voltage pulsed current (HVPC)
electrotherapy
Patient Education
28
Venous Insufficiency
29
Venous Insufficiency Ulcers
Location
– Medial aspect of the lower leg and ankle
– Superior to medial malleolus
30
31
Venous Insufficiency Treatment
Surgical obliteration of damaged veins
Elevation of legs
*Compression therapy to provide at least
30mm Hg compression at the ankle
– Short stretch bandages (e.g. Setopress,
Surepress)
– Therapeutic support stockings
– Unna’s boot
– Profore layer wrap
– Compression pumps
*ensure compression therapy in not contraindicated
32
Venous Insufficiency Treatment
Topical Therapy
Absorb exudate (e.g. alginate, foam)
Maintain moist wound surface (e.g. hydrocolloid)
Chronic or non-responding wounds:
Small Intestinal SubmucosaTechnology (Oasis
Wound Matrix; Healthpoint)
Bi-layered cell therapy (Apligraf;
Organogenesis, Inc.)
Patient Education
Appropriate antibiotics to treat infection
33
Peripheral Neuropathy/Diabetic
Signs & Symptoms
Relief of pain with ambulation
Parasthesia of extremities
Altered gait
Orthopedic deformities
Reflexes diminished
Altered sensation (numbness, prickling,
tingling)
34
Peripheral Neuropathy/Diabetic
Signs & Symptoms
Intolerance to touch (e.g., bed sheets
touching legs)
Presence of calluses
Fissures/cracks, especially the heels
Arterial insufficiency commonly co-exists
with peripheral neuropathy!
35
Peripheral Neuropathy
Diabetic Location
Plantar aspect of the foot
Metatarsal heads
Heels
Altered pressure points
Sites of painless trauma and/or repetitive
stress
36
37
Peripheral Neuropathy
Diabetic Treatment
Pressure relief for heal ulcers
“Offloading” for plantar ulcers (bedrest,
contact casting, or orthopedic shoes)
Appropriate footwear
Tight glucose control
Aggressive infection control
orthopedic consult for exposed bone and antibiotic
therapy
Zyvox – approved for MRSA
Treatment for co-existing arterial
insufficiency
38
Peripheral Neuropathy
Diabetic Treatment
Topical Treatment
– Cautious use of occlusive dressings
– Dressings to absorb exudate
– Dressings to keep dry wound moist
Chronic or non-responding wounds:
– Recombinant human platelet-derived growth
factors (Regranex Gel; Johnson & Johnson)
– Human fibroblast-derived dermal substitute
(Dermagraft; Smith & Nephew)
– Bi-layered cell therapy (Apligraf;
Organogenesis, Inc.)
39
Peripheral Neuropathy
Diabetic Treatment
Adjunctive Therapy
Hyperbaric Oxygen
MIRE - nitric oxide and monochromatic
infrared photo energy (Anodyne Therapy LLC,
Tampa, FL)
The V.A.C (KCI)
Patient Education
40
Mixed Etiology
41
Mixed Etiology
Use reduced compression bandages of
23-30 mm Hg at the ankle. Compression
therapy should not be used in patients with
ABI < 0.5
Keep extremities in neutral position
Protect from trauma
42
Pressure Ulcers
Pressure Ulcers
44
Contributing factors:
Friction
45
Contributing factors:
Friction
46
Contributing factors: Shear
47
Contributing factors: Shear
48
Contributing factors:
Moisture
49
Contributing factors:
Moisture
50
Topical Treatment
 Wound Debridement
 Removal of devitalized tissue is considered
necessary for wound healing
Exception: Stable heel ulcers with a protective
eschar covering with no signs or symptoms of
edema,erythema, fluctuance, or drainage, do NOT
need debridement
51
Wound Debridement
 Mechanical: Use of wet-to-dry,
hydrotherapy and wound irrigation to remove
devitalized tissue
 Disadvantage: non-selective, painful
and can lead to excessive bleeding
 NOTE: A wet-to-dry dressing should
be used for debridement purposes
ONLY
52
Wound Debridement
 Pulsatile Lavage
– It is a form of mechanical
debridement to facilitate removal
of larger amounts of debris
– Irrigation pressure should not
exceed 15psi
– It is best discontinued once the
wound is clean
53
Pulsatile Lavage
– It can cause dissemination of wound bacteria
over a wide area, exposing the resident and
care provider to potential contamination (JAMA
Vol. 292 No. 24, December 22/29, 2004 & Nursing 2005,
January 2005 Issue)
– Study at John Hopkins University School of
Medicine, traced 11 patients infected with
acinetobacter baumannii, back to the use of
pulsatile lavage equipment. 3 of the patients
required ICU care for sepsis and respiratory
distress
54
Pulsatile Lavage
– Precautions must be used
» Use continuous suction
» Keep splash shield in contact with the
wound/periwound
» Empty suction waste container after each
use
» Dispose of all single-use pulsatile lavage
components, then sterilize or disinfect all
reusable items
» Always perform pulsatile lavage in a private
room enclosed with walls and doors
» Thoroughly clean and disinfect
environmental surfaces
55
Pulsatile Lavage
Precautions continued
»Wear fluid proof gown,
mask/goggles or face shield and
hair cover
»Resident should consider the use
of a droplet barrier, such as a
surgical mask
»Use a drape or towel to cover all
resident lines, ports and wounds
that aren’t being treated
56
THANK YOU!!!
Jeri Lundgren, RN, CWS,
CWCN
Wound Care Consultant
Pathway Health Services
612-805-9703
[email protected]
57