PRESSURE ULCERS

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PRESSURE ULCERS

• Kansas Reynolds Program in Aging
• Scholars Seminar Series
• November 30, 2007
• Shelley B. Bhattacharya, D.O., M.P.H.
• Assistant Professor, Director of Geriatric
  Education

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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

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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)

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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 gt10 over 1
  year or low albumin or prealbumin levels), THEN
  nutritional intervention or dietary consultation
  should be instituted

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TOPICS COVERED

• Epidemiology
• Complications
• Risk Factors and Risk Assessment
• Evidence based review of prevention techniques
• Ulcer Assessment and 2007 Staging definitions
• Monitoring and Treatment

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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

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PRESSURE ULCERS A MAJOR ISSUE IN GERIATRIC
MEDICINE

• Affects 1 million adults annually
• Higher risk in older persons because
• 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

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Pressure Ulcer Staging
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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
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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.
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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
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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
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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
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PREVALENCE OF PRESSURE ULCERS VARIES BY SETTING

• 1 to 30

• 3 to 30

5 to 15
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PREVALENCE OF PRESSURE ULCERS VARIES BY STAGE
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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

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INTRINSIC FACTORS PREDICTIVE OF PRESSURE ULCER
DEVELOPMENT

• 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

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EXTRINSIC FACTORS PREDICTIVE OF PRESSURE ULCER
DEVELOPMENT

• 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

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Usual pressure ulcer locations

• Over Bony Prominences
• Occiput
• Ears
• Scapula
• Spinous Processes
• Shoulder
• Elbow
• Iliac Crest
• Sacrum/Coccyx
• Ischial Tuberosity
• Trochanter
• Knee
• Malleolus
• Heel
• Toes

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Other locations

• Any skin surface subject to excess pressure
• Examples include skin surfaces under
• Oxygen tubing
• Urinary catheter drainage tubing
• Casts
• Cervical collars

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POSSIBLE COMPLICATIONS

• Sepsis (aerobic or anaerobic bacteremia)
• Localized infection, cellulitis, osteomyelitis
• Pain
• Depression
• Mortality rate 60 in older persons who
  develop a pressure ulcer within 1 year of
  hospital discharge

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RISK ASSESSMENT INSTRUMENTS

• Widely used tools for identifying older patients
  at risk for developing ulcers SCREENING TOOLS
• Norton scale
• sensitivity 7392, specificity 6194
• Braden scale
• sensitivity 83100, specificity 6477
• Both recommended by Agency for Healthcare
  Research and Quality

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BRADEN SCALE

• Provides method for assessing a patients
  pressure ulcer risk by evaluating
• Sensory perception ability to respond to
  pressure-related 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

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NORTON SCALE

• Provides method for assessing a patients
  pressure ulcer risk by evaluating
• Physical condition
• Mental condition
• Level of physical activity
• Mobility
• Continence or incontinence

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Scale Documentation Frequency

• October 2007 JAGS article recommends using the
  scales
• 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.

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PREVENTION

• An evidence-based approach to preventing
  pressure ulcers focuses on
• Skin care
• Mechanical loading
• Support surfaces

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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

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PREVENTIONMECHANICAL 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)

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Heel Ulcers
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PREVENTING HEEL ULCERS

• Assess heels of high-risk patients every day
• Use moisturizer on heels (no massage) twice a day
• Apply dressings to heels
• Transparent film for patients prone to friction
  problems
• Single or extra-thick hydrocolloid dressing for
  those with pre-stage 1 reactive hyperemia

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PREVENTING HEEL ULCERS

• Have patients wear
• Socks to prevent friction (remove at bedtime)
• Properly fitting sneakers or shoes when in
  wheelchair
• Place pillow under legs to support heels off bed
• Place heel cushions to prevent pressure
• Turn patients every 2 hours, repositioning heels

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PRESSURE-REDUCINGSUPPORT SURFACES

• Use for all older persons at risk for ulcers
• Static
• Foam, static air, gel, water, combination (less
  expensive)
• Dynamic
• Alternating air, low-air-loss, or air-fluidized
• Use if the status surface is compressed to lt1
  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

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SUPPORT SURFACES
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MANAGEMENT GENERAL ASSESSMENT

• Identify and effectively manage issues that have
  placed patient at risk for pressure ulcers
• Medical diseases
• Health problems (eg, urinary incontinence)
• Nutritional status
• Pain level
• Psychosocial health

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MANAGEMENT ULCER ASSESSMENTEvaluate and
document the following

• Location
• Stage
• Area
• Depth
• Pain

• Drainage
• Necrosis
• Granulation
• Cellulitis

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MANAGEMENTMONITORING HEALING

• Document all observations over time
• Describe each ulcer to track progress of healing
• Do not use reverse staging
• 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)

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PRESSURE ULCER SCALE FOR HEALING (PUSH)

• A validated method to document healing over time
• Observe and measure the ulcers
• 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

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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

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MANAGEMENTCONTROL OF INFECTIONS

• Wound cleansing and dressing are the key
• ? 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

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MANAGEMENTCONTROL OF INFECTIONS

• If still no healing, consider presence of
• Cellulitis--
• Biopsy for culture of underlying tissue, bone
• May need systemic antibiotics
• or Osteomyelitis
• Staphylococcus aureus is by far the most commonly
  involved
• X-RaySoft tissue swelling, bone destruction
  (10-21 d after infection)
• CTMedullary and cortical destruction
• MRIBetter 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.

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MRI views of osteomyelitis
Courtesy Lancet 2004 Jul 24364(9431)369
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Bacterial Culture Collection

• 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

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MANAGEMENTMETHODS OF DEBRIDEMENT
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MANAGEMENTDRESSINGS

• Transparent film stage I, protects from friction
• Contraindicated skin tears, draining, suspected
  infection
• Foam island stages II, III
• Contraindicated excessive exudate dry, crusted
  wound
• Hydrocolloid stages II, III
• Contraindicated poor skin integrity, infection,
  wound needs packing
• Petroleum-based nonadherent stages II, III,
  graft sites

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MANAGEMENTDRESSINGS

• Calcium Alginate stages II, III, IV, excessive
  drainage
• Contraindicated dry or superficial wound with
  maceration
• Hydrogel, amorphous stages II, III, IV must
  combine with gauze dressing
• Contraindicated maceration, excess exudate
• Hydrogel, sheet stage II, skin tears
• Contraindicated maceration, moderate to heavy
  exudate
• Gauze packing stages III, IV, deep wounds

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MANAGEMENTNUTRITION

• 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 pressure
  ulcer development and healing

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Nutrition and Ulcersthe evidence!

• 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

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MANAGEMENTSURGICAL 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

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MANAGEMENTADJUNCTIVE THERAPIES

• No data to support low-energy laser irradiation,
  therapeutic ultrasound
• Promising research continues
• Recombinant platelet-derived growth factors
• Electrical stimulation
• Vacuum-assisted closures
• Warm-up therapy ( ? basal ulcer temperature
  promotes healing)
• Hyperbaric oxygen

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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

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CASE 1 (1 of 2)

• In a hospital, which of the following is the best
  approach to identify residents at risk for
  development of pressure ulcers and to monitor
  existing pressure ulcers?
• Develop risk and monitoring scales specific to
  that facility.
• Implement the Braden scale and the Pressure Ulcer
  Scale for Healing (PUSH).
• Implement the Braden and Norton scales.
• Implement the PUSH tool and the Pressure Sore
  Status Tool (PSST).

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CASE 1 (2 of 2)

• In a nursing facility, which of the following is
  the best approach to identify residents at risk
  for development of pressure ulcers and to monitor
  existing pressure ulcers?
• Develop risk and monitoring scales specific to
  that facility.
• Implement the Braden scale and the Pressure Ulcer
  Scale for Healing (PUSH).
• Implement the Braden and Norton scales.
• Implement the PUSH tool and the Pressure Sore
  Status Tool (PSST).

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CASE 2 (1 of 3)

• Your colleagues 82-year-old nursing home
  resident is evaluated in the hospital because she
  has developed full-thickness pressure ulcers on
  both heels.
• She has a history of multiple sclerosis,
  dementia, and urinary incontinence.

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CASE 2 (2 of 3)

• Which of the following is the most appropriate
  mattress for this patient?
• (A) Air mattress
• (B) Foam mattress
• (C) Water mattress
• (D) Low-air-loss mattress
• (E) Air-fluidized mattress

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CASE 2 (3 of 3)

• Which of the following is the most appropriate
  mattress for this patient?
• (A) Air mattress
• (B) Foam mattress
• (C) Water mattress
• (D) Low-air-loss mattress
• (E) Air-fluidized mattress

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CASE 3 (1 of 3)

• A 74-year-old man, recently admitted to your
  inpatient service, has developed a pressure ulcer
  on his left heel over the past few days.
• He has a history of mild dementia,
  non?insulin-dependent diabetes mellitus,
  hypertension, and coronary artery disease. He has
  left hemiparesis from a stroke.
• On examination, the ulcer is 5 ? 3 cm. There is
  necrosis of the subcutaneous tissue, partial
  exposure of the underlying fascia, a moderate
  amount of slough, and a large amount of exudate.
  Erythema surrounds the ulcer, but there is no
  induration.

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CASE 3 (2 of 3)

• Which of the following is the most appropriate
  treatment for the ulcer?
• (A) Calcium alginate dressing
• (B) Collagen granules covered with dry gauze
• (C) Sequential use of calcium alginate and
  hydrocolloid
• dressings
• (D) Wet-to-dry dressing

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CASE 3 (3 of 3)

• Which of the following is the most appropriate
  treatment for the ulcer?
• (A) Calcium alginate dressing
• (B) Collagen granules covered with dry gauze
• (C) Sequential use of calcium alginate and
  hydrocolloid
• dressings
• (D) Wet-to-dry dressing

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References

• Geriatrics Review Syllabus, 6th edition, p259-268
• Bates-Jensen, B et al. Quality Indicators for the
  care of pressure ulcers in vulnerable elders
  JAGS 55S409-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.

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References

• http//www.nursingquality.org/NDNQIPressureUlcerTr
  aining/index2.htm
• www.medicaledu.com - Wound Care 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 24364(9431)369