CARE GUIDE for Pressure Ulcers

Prevention (1,3) Risk assessment should be performed in both the inpatient and outpatient setting Evaluate for susceptibility for pressure ulcer using a standardized tool such as the Braden Scale The Braden scale can be obtained at: http://www.bradenscale.com/i mages/bradenscale.pdf Nutritional Assessment (1,2,3,6) Evaluate nutritional status for pressure ulcer prevention and susceptibility for poor wound healing CARE GUIDE for Pressure Ulcers Patients at risk: Those with previous pressure ulcer, spinal cord injury, peripheral vascular disease, orthopedic conditions, at extremes of age, in critical care, undergoing surgery, after myocardial infarction, stroke, multiple trauma, gastrointestinal (GI) bleed, neurological disorders, and dementia Assess patients using a recognized nutritional assessment tool. One such tool is the Mini Nutritional Assessment (MNA) which can be found at: http://www.mnaelderly.com/forms/mini/mna_m ini_english.pdf Assess patient s ability to eat independently (3) Evaluate the skin in patients at high risk for pressure ulcer A skin inspection should be done on patients within 6 hours of an admission, and re-inspection should be done every 8-24 hours, depending on the status of the patient Develop a skin safety plan for high risk patients which includes the following elements: Minimize friction and shear Minimize pressure Manage moisture Maintain adequate nutrition/hydration Provide nutritional support as needed Provide nutritional supplements and food fortifiers as indicated Provide multi-vitamin and mineral supplement, including zinc and vitamin C, if intake is poor or nutritional deficiency is suspected or indicated by lab values Monitor lab values. Serum prealbumin levels can be interpreted as follows: Less than 5mg/dL predicts a poor prognosis Reposition patients frequently, at least every 2 hours if bedridden Assess for and provide pressure redistributing devices as needed Educate patient and caregiver(s) on prevention and treatment of pressure ulcers including repositioning, pressure redistributing devices, use of assistive devices to reduce friction/shear, minimizing macerated skin and adequate nutrition/hydration for the prevention of or healing of pressure ulcers Re-assess as patient s condition changes and document findings Referral to a registered dietician for nutritional assessment is recommended for all patients (1, 3) who are: at risk for development of a pressure ulcer 1, or presenting with a pressure ulcer (1,3) 1

Assessment of Pressure Ulcers (1,3) Assess and categorize/stage each ulcer using the National Pressure Ulcer Advisory Panel s classification/ staging system Note: Using reverse categorizing/staging as pressure ulcers heal is not recommended Assessment of the individual with a pressure ulcer should include: (3) A complete health/medical and social history Focused examination that includes Factors that may affect healing (e.g., impaired perfusion, impaired Suspected Deep Tissue Injury (DTI): 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. Deep tissue injury may be hard to detect in individuals with dark skin tones. 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 Less than 11mg/dL predicts high risk and requires aggressive nutritional supplementation Less than 15mg/dL predicts an increased risk of malnutrition\ Nutritional interventions may be able to reduce the number of people who develop pressure ulcers, more evidence is needed to identify effective dietary interventions Design treatment plan for specific findings of ulcer Tips: (1) If it is dirty, clean it If it is deep, fill it If it is open, cover it If it is dry, moisten it If it is wet, absorb it Reassess at least weekly, document findings and, change treatment plan as indicated 2

sensation, systemic infection Vascular assessment if extremity ulcers present Laboratory tests and x- rays as needed Nutritional assessment Pain related to pressure ulcers Risk for developing additional pressure ulcers Psychological health, behavior and cognition Functional capacity, particularly in regard to positioning, posture, and the need for assistive equipment and personnel The employment of pressure-relieving maneuvers Adherence to pressurerelieving maneuvers Integrity of seating and bed surfaces The individual s/family members knowledge and belief about developing and healing pressure ulcers layers of tissue even with optimal treatment, (1,3) Category/Stage 1: 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 1 may be difficult to detect in individuals with dark skin tones. May indicate at risk persons. (1,3) Category/Stage 2: Partial thickness loss of dermis presenting as a shallow, open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Further description: Present as a shiny or dry shallow ulcer without slough or bruising. Bruising indicates suspected deep tissue injury. This stage should not be used to describe tears, tape burns, 3

Assess progress toward healing using one or more validated tools: (3) Pressure Ulcer Scale for Healing (PUSH ) Tool Bates-Jensen Wound Assessment Tool (BWAT) formerly known as the Pressure Sore Status Tool (PSST) National Pressure Ulcer Advisory Panel (NPUAP) Wound Healing Scale (WHS Sussman Wound Healing Tool (SWHT) Use clinical judgement to assess signs of healing such as decreasing amount of exudate, decreasing wound size, and improvement in wound bed tissue perineal dermatitis, maceration or excoriation. (1,3) Category/Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles 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 (1,3) Category/Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Further description: The depth of stage IV pressure ulcer 4

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 IV ulcers can extend into muscle and/or supporting structure (e.g., fascia, tendon or joint capsule), making osteomyelitis possible. Exposed bone/tendon is visible and directly palpable (1,3) Unstageable/Unclassified: 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 wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, 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 (1,3) 5

Treatment of Pressure Ulcers (1,3,6) Design treatment program for patient findings History and physical (see Patients at risk above) Etiology of pressure Psychosocial needs Nutritional status (see above) Wound and skin health (wound description and staging) Bacterial colonization/ infection Patient should have access to pressure relieving devices 24 hrs/day Need to consider all surfaces used by patient (see below) Common location of pressure ulcers occur over bony prominences or are equipmentrelated Isolation, pain, financial problems, lack of privacy, change in body image, loss of independence impact recovery Monitor wound for signs of bacterial colonization or infection Monitor wound healing using a standardized tool Identify source of pressure and reduce or eliminate it Apply holistic approach to care Protect from contamination Dressing or topical agent Tissue biopsy or wound culture if necessary Debridement (sharp, chemical/enzymatic, mechanical, autolytic, or biosurgical or larval) as needed. Antimicrobial therapy for colonization (topical treatment) or infection (systemic treatment) Organize care delivery to ensure that is coordinated with pain medication administration (3) Use adequate pain-control measures, including additional dosing at times of wound manipulation, wound cleansing, dressing change, debridement, etc. (3) Consider premedication prior to wound care when indicated (1) Employ lidocaine/prilocaine preparations to reduce pain during debridement and dressing changes Surgical referral if indicated Reassess frequently, document findings, and adjust treatment plan accordingly 6

Pressure Relieving Devices (1,5,13) Need to consider all surfaces used by patient Immunizations (4) Influenza Vaccination Categorizing of wounds as indicated above Document patient has an influenza vaccination each year Document if adverse event occurs Category/Stage 1-2 highspecification foam mattress (redistribute pressure over a larger contact area) Category/Stage 3-4 highspecification foam mattress with alternating pressure overlay OR continuous low pressure system The American College of Physicians recommends the use of static mattresses or advanced static overlays in patients who are at an increased risk of developing pressure ulcers (5) Administer vaccine yearly Change pressure relieving device when risk status changes or when the patient s condition changes Yearly Pneumonia Vaccination Document patient has received a pneumonia vaccination Document if adverse event occurs There are two different types of pneumococcal vaccine: PCV13 (pneumococcal conjugate PPSV23 (pneumococcal (polysaccharide vaccine) Administer appropriate vaccine as indicated http://www.cdc.gov/vaccines/schedules /hcp/adult.html As indicated 7

Tobacco Use (7-12) Smoking cessation Tobacco use patterns Prior attempts to quit Readiness assessment Combination therapy with counseling and medications is more effective than either component alone Use of e-cigarettes Think: 5 A's Ask about smoking Advise to quit Assess willingness to quit Assist user to quit (i.e., refer to smoking cessation program and consider pharmacotherapy) Arrange follow-up Call on quit date or within 72 hours to boost self-efficacy Assess at each visit: smoking status, weight gain, nicotine withdrawal symptoms Factors to consider when choosing a pharmacotherapy (7) Clinician familiarity with the medications and contraindications for selected patients Previous patient experience with a specific pharmacotherapy (positive or negative) Patient characteristics (e.g., history of depression, concerns about weight gain First line pharmacotherapy adjuvants (7) Nicotine replacement Sustained-release bupropion Varenicline Second-line pharmacotherapies (7) Clonidine and nortriptyline Consider using second-line pharmacotherapies for patients who are unable to use first-line medications because of contraindications or for patients for whom first-line medications are not helpful, Monitor patients for known side effects of second-line agents e-cigarettes (8) Not FDA approved or regulated Not enough information about safety or effectiveness for cessation 8

One of the FDA-approved safe and effective cessation medications is recommended These guidelines are intended as an educational reference and not as a substitute for the clinical judgment of the treating physician concerning appropriate and necessary care for a specific patient. These guidelines are based on the clinical references listed at the end of the document. Note that a specific treatment or therapy listed may not be a covered benefit for all individuals. Please check the individual s eligibility and benefits plan. REFERENCE LIST 1. Perry D, Borchert K, Burke S, et al. (2014). Health Care Protocol: Pressure Ulcer Prevention and Treatment Protocol. Institute for Clinical Systems Improvement (ICSI) Retrieved May 15, 2015 from https://www.icsi.org/_asset/6t7kxy/pressureulcer.pdf 2. DiMaria-Ghalili R, Amella E. (2012). Assessing Nutrition in Older Adults. The Hartford Institute for Geriatric Nursing, Issue Number 9. Retrieved June 5, 2014 from http://consultgerirn.org/uploads/file/trythis/try_this_9.pdf 3. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Ulcer alliance. (2014). Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Retrieved May 18, 2015 from http://www.npuap.org/wp-content/uploads/2014/08/updated-10-16-14-quick- Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf 4. Centers for Disease Control and Prevention (CDC). (2015) Recommended Adult Immunization Schedule, by Vaccine and Age Group. Retrieved May 18, 2015 from http://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html 5. Qaseem A, Mir T, Starkey M, Denberg T. (2015). Risk Assessment and Prevention of Pressure Ulcers: A Clinical Practice Guideline from the American College of Physicians. 162:359-369. Retrieved 5/15/15 from http://annals.org/article.aspx?articleid=2173505 6. A Humphrey L, Forciea M, Starkey M, and Denberg T. (2015). Treatment of Pressure Ulcers: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med, 162:370-379. Retrieved May 18, 2015 from http://annals.org/article.aspx?articleid=2173506 9

7. Agency for Healthcare Research and Quality (AHRQ) (2012). Clinical Guidelines for Prescribing Pharmacotherapy for Smoking Cessation. Retrieved 2/3/15 from http://www.ahrq.gov/professionals/clinicians-providers/guidelinesrecommendations/tobacco/prescrib.pdf 9. Fiore MC, Jaen CR, Baker TB, et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. Retrieved 2/3/15 from http://www.ahrq.gov/professionals/clinicians-providers/guidelinesrecommendations/tobacco/clinicians/update/treating_tobacco_use08.pdf 11. Hughes J, Stead L, Hartmann-Boyce J, Lancaster T. (2014). Antidepressants for smoking cessation (Review). Cochrane Database Syst Rev. Retrieved 2/3/15 from http://onlinelibrary.wiley.com/doi/10.1002/14651858.cd000031.pub4/pdf 8. Naftilan, Allen J., Associate Professor of Medicine, Vanderbilt University Medical School; Clinical Director, The Heart Failure Program, The Vanderbilt Heart Institute, Nashville, Tennessee 10. Henningfield JE, Fant RV, Buchhalter AR, Stitzer ML. (2005). Pharmacotherapy for Nicotine Dependence. CA Cancer J Clin. 55:281-99. Retrieved 2/3/15 from http://onlinelibrary.wiley.com/doi/10.3322/canjclin.55.5.281/pdf 12. U.S. Preventive Services Task Force. (2009). Tobacco Use in Adults and Pregnant Women: Counseling and Interventions. Retrieved 2/9/15 from http://www.uspreventiveservicestaskforce.org/page/topic/recommendationsummary/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions 13. Chou R, Dana T, Bougatos C, Blazina I, Starmer A, Relterl K and Buckley D. (2013). Pressure Ulcer Risk Assessment and Prevention. Ann of Int Med, Vol 159:28-38. Retrieved May 28, 2015 from http://annals.org/article.aspx?articleid=1700643 10