4587 Pressure Ulcers Prevention, Care & Management Study Guide
Prevention, Care and Management Video produced and distributed by: Envision, Inc. 644 West Iris Drive Nashville, TN 37204 1-866-321-5066 www.envisioninc.net Kimberly-Clark Health Care Education 3
ACKNOW LEDGEMENTS We would like to express our sincere appreciation to the following individuals CLINICAL ADVISORS Marianne Charest, RN Baystate Medical Center Margaret Curran Kugler, MS, CRNP The Wound Healing Center Georgetown University Hospital Sheree Lee, RN, CWOCN WOCN Manager Vanderbilt University Medical Center Cynthia Sylvia, MSc, MA, RN, CWOCN Program Manager, Educational Development Gaymar Industries, Inc. Dennis J. Woytowicz, RN Intensive Care Unit Baystate Medical Center FILMING LOCATION Vanderbilt University Medical Center Nashville, Tennessee Envision, Inc. 2008 This program sponsored in part through an unrestricted educational grant provided by Gaymar Industries, Inc 4
Prevention, Care & Management Table of Contents I. Introduction................................................................................................... 7 II. Objectives.................................................................................................... 8 III. Are All Pressure Ulcers Preventable?............................................................................ 8 IV. Monitoring and Reassessment................................................................................. 10 A. Risk Factors............................................................................................... 10 1. Extrinsic............................................................................................... 10 2. Intrinsic................................................................................................ 11 B. Risk Assessment Tools...................................................................................... 11 C. Assessing the Skin......................................................................................... 12 D. Assessing the Wound....................................................................................... 13 1. Staging the Pressure Ulcer................................................................................. 13 2. Describing the Pressure Ulcer.............................................................................. 14 3. Measuring the Wound.................................................................................... 15 E. The Nutritional Assessment.................................................................................. 16 F. The Pain Assessment....................................................................................... 17 G. The Psychosocial Assessment................................................................................ 17 H. Operating Room Considerations............................................................................... 17 V. Implement Prevention Protocols to Address Risk Factors......................................................... 18 A. Protect Skin Integrity....................................................................................... 19 B. Determine and Manage Moisture and Incontinence............................................................... 19 C. Practice Pressure Redistribution.............................................................................. 20 D. Manage the Wound Bed Effectively........................................................................... 22 1. Improve/Maintain Mobility and Activity...................................................................... 23 2. Cleanse the Wound with Every Dressing Change............................................................... 24 3. Select the Most Appropriate Dressing....................................................................... 24 E. Promote the Growth of Healthy Tissue......................................................................... 25 F. Minimize Pain............................................................................................. 27 G. Meet Nutrition and Hydration Needs.......................................................................... 27 H. Meet Psychosocial Needs................................................................................... 28 I. Improve/Maintain Mobility and Activity........................................................................ 28 VI. Monitoring and Re-Assessment................................................................................ 28 VII. Promptly Identify and Manage Complications.................................................................... 29 A. Complications............................................................................................. 29 B. Treatment................................................................................................ 30 C. Reevaluating Current Treatment.............................................................................. 30 VIII. Discharge and Transfer....................................................................................... 29 IX. Education.................................................................................................... 31 X. Conclusion................................................................................................... 32 XI. References.................................................................................................. 33 XII. Tools........................................................................................................ 38 XIII. Post Test..................................................................................................... 40 XIV. Resources................................................................................................... 42 XV. Post Test Answers............................................................................................ 43 Kimberly-Clark Health Care Education 5
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I. Introduction Pressure Ulcers Prevention, Care & Management Pressure ulcers are one of the greatest challenges facing caregivers of both acute and long term care facilities. They are potentially devastating to patient s quality of life - causing pain, affecting functional status and creating psychological trauma. Patients and their families sometimes view pressure ulcers as abuse and neglect, despite healthcare workers best efforts. Pressure ulcers can cost health care facilities billions a year in treatment costs and legal fees due to serious infections and other complications that can be life-threatening. Here are some statistics: Nearly 1 million individuals develop pressure ulcers per year, and 60,000 people in acute care die from related complications. 1 The incidence of pressure ulcers in acute care is 0.4% to 38%, with intensive care units (ICU) ranging from 8% to 40. 23 The highest prevalence of pressure ulcers is seen in LTC facilities, but the highest incidence is in acute care. 3 More than 75% of pressure ulcers are superficial skin damage (Stage I at 37%, Stage II at 39%). 4 Regardless of the healthcare setting, pressure ulcers increase the amount of nursing care required, the patient s length of stay, and associated healthcare costs. On average, the cost to treat a pressure ulcer is between $1,119 and $10,185 5 while the cost to treat severe ulcers may cost as much as $55,000. 6 Patients who develop pressure ulcers are also more likely to develop healthcare-associated infections and other complications that are associated with substantial and significant increases in hospitals costs and length of stay. 7 The most common locations for pressure ulcers are the sacrum or ischium, followed by the heel. 4 The majority of patients are over the age of 70. 4 Preventing and treating pressure ulcers are so important that acute care facilities are now under tremendous pressure to follow new regulations, standards and guidelines. CMS released the final rule on the 2008 Medicare Hospital Inpatient Prospective Payment System (IPPS) related to Hospital Acquired Conditions-Present On Admission (HAC-POA) that includes provisions to ensure that Medicare no longer pays for costs associated with preventable conditions acquired during care, one of which is pressure ulcers. 8 The National Quality Forum, a non-profit coalition of physicians, hospitals, businesses and policy-makers, has identified pressure ulcers as one of 28 serious reportable events or never events. 9 The Joint Commission has named the prevention of healthcare acquired pressure ulcers as a Patient Safety Goal since 2006. 10,11 There are initiatives to prevent pressure ulcers by the Institute for Healthcare Improvements (IHI) Protecting 5 Million Lives from Harm Campaign 12 and the Association for Advanced Wound Care (AAWC) Quality of Care Task Force. 13 There are numerous best practice guidelines such as those by the National Pressure Ulcer Advisory Panel (NPUAP), 14,15 the Wound, Ostomy and Continence Nurses Society (WOCN), 16 American Medical Directors Association (AMDA), 17,18 Harford Institute for Geriatric Nursing (HIGN), 19 The Agency for Health Care Research and Quality (AHRQ) 20,21 and the Registered Nurses Association of Ontario (RNAO). 22 Training on pressure ulcer prevention, treatment and management is a required nurse-sensitive quality indicator for the ANCC Magnet Recognition Program. 23 Kimberly-Clark Health Care Education 7
Prevention, Care and Management If we are to ensure compliance with CMS and accreditation agencies and provide our patients with the care they deserve, then healthcare professionals from various disciplines, such as physicians, registered nurses, nursing assistants, physical and occupational therapists, pharmacists, and dietitians who have direct contact with patients must become aware of the risks of pressure ulcers, be able to assess for level of risk in patients, and learn strategies for prevention and management. 12,17,24 The message is clear: Regardless of probable outcomes, providers must take all possible steps to prevent and treat pressure ulcers. NOTE: Due to the special complexities of the pediatric population, of residents of long term care, and of patients in home health settings, it is the decision of the authors of this program to only focus on the prevention, care and management of pressure ulcers in adults in the acute care setting. II. Objectives After completing this program, the learner will be able to: Define pressure ulcers according to the NPUAP Staging system Describe the risk factors associated with the development of pressure ulcers Discuss three strategies to prevent pressure ulcers Explain three principles of wound care related to the treatment of pressure ulcers III. Are All Pressure Ulcers Preventable? The goal of this program and of the various guidelines and initiatives mentioned previously is to prevent pressure ulcers. Yet, while many pressure ulcers are avoidable, even with the best of care some very high-risk patients may develop pressure ulcers such as individuals with compromised immune systems, the terminally ill and those with spinal cord injuries. 20,25 Regardless of risk, all efforts should be made to reduce risk factors, implement preventive measures, and provide treatment whenever possible and in accordance with the plan of care. 20 CMS defined Avoidable vs. Un-avoidable pressure ulcers for the long term care setting in its publication Guidance to Surveyors for Long Term Care Facilities. 27 It should be noted that with regards to hospitals and the recent IPPS rule, CMS is using Tag F314 and its experience with pressure ulcers in the long term care setting to serve as a model for hospital compliance. 28 The following definitions may be considered by hospitals with Medicare/Medicaid patients as a guidance for creating and implementing protocols. 8
Prevention, Care & Management CMS defines an avoidable pressure ulcer as one that developed and the facility failed to do one or more of the following: 27 Evaluate the clinical condition and/or risk factors Define and implement interventions consistent with the needs and goals of the patient Use recognized evidence-based standards of practice, such as those offered by the Wound, Ostomy and Continence Nurses Society (WOCN) Monitor and evaluate the impact of interventions Revise interventions appropriately On the other hand, an unavoidable pressure ulcer is one that a patient develops even though the facility: 27 Evaluated the residents clinical condition and pressure ulcer risk factors Defined and implemented interventions that are consistent with the resident s needs, goals, and recognized standards of practice Monitored and evaluated the impact of the interventions Revised approaches as appropriate CMS requires long term care facilities to document every aspect of an unavoidable pressure ulcer, such as why the risk factors can lead to a pressure ulcer. There are studies that have shown a reduction in healthcare-associated pressure ulcers with a well designed prevention program and protocols. 29,30 For example, a two-hospital system in Florida with all adult patients developed a program that tied a risk assessment to automatic consults, pressure ulcer redistribution measures with personnel augmentation and new equipment, and an interprofessional team to decide on protocols. Over a period of 4.5 years, pressure ulcers were reduced by 81%, and heel ulcers alone were reduced by 90%. 30 Even critically ill patients in intensive care who are at increased risk for pressure ulcers can have decreased frequency. A study over a 26-month period in Sydney, Australia found a 42% reduction in the prevalence of pressure ulcers following one-on-one clinical instruction of beside nurses and the appropriate allocation of pressure-relieving devices. 29 The success of a prevention program relies upon nurse staff support. This point was brought home by a study in California that compared results before and after an intervention program and found very little improvement in the incidence of pressure ulcers. The failure of the prevention program was attributed to a lack of evidence-based practices, effective education, as well as a conveyance by management of the vital importance of a pressure ulcer prevention program and of management support of prevention efforts. 31 The Pressure Ulcer Prevention and Management Plan There are three key elements in a successful pressure ulcer prevention plan: Assessment of risk Implementation of prevention protocols to address risk factors Education of staff and patients In addition, to best manage patients with pressure ulcers, clinicians must be able to: Monitor and re-assess the patient to ensure adequate healing and prevent future ulcers Promptly identify and treat complications These elements can be used to prevent the creation of new and additional pressure ulcers, as well as manage patients with pressure ulcers. Kimberly-Clark Health Care Education 9
Prevention, Care and Management IV. Assessment of Risk Pressure ulcers can develop in as little as two hours and typically develop within the first 24 to 48 hours following admission. 32 Therefore, prompt identification of patients at risk is the critical first step in preventing pressure ulcers and ensuring your facility s compliance with CMS, The Joint Commission, and other accreditation and regulating agencies no matter where you work in the continuum of care. In the new hospital IPPS ruling, CMS states that pressure ulcers that are not identified as present on admission (POA) will not be paid for. By selecting this condition, CMS believes this ruling will result in hospitals conducting a closer examination of a patient s skin upon admission, and providing better quality of care. 26 In order to predict an individual s risk for a pressure ulcer, a comprehensive initial assessment for risk factors should be conducted upon admission, and re-assessments should be performed regularly and when there is a significant change in the individual s condition. 16,18 Assessments and reassessments should be based on the patient s individual needs, the care environment, as well as the regulations and guidelines applicable to the healthcare setting. 33 The WOCN and NPUAP recommend the following assessment guidelines: 14,16 In acute care: Patients should be assessed upon admission, reassessed at least every 48 hours, and whenever a patient s condition changes or deteriorates. In the ICU, stable patients may be assessed daily, and unstable patients assessed each shift. The initial assessment may include: 11,14,16,18,22 A comprehensive medical history and physical examination Pressure ulcer assessment and documentation, including history of pressure ulcers, current ulcers, previous treatments or surgical interventions that increase risk for additional pressure ulcers Assessment of other factors such as nutritional status, co-morbidities, pain and psychosocial issues Assessment of potential complications, such as fistula, abscess, osteomyelitis, bacteremia, cellulitis and cancer Assessment of factors that impede healing status, such as co-morbid conditions or medications A. Risk Factors Risk factors can vary by setting, but in general, there are certain patients who are at higher risk than others for developing pressure ulcers. These risk factors are divided into extrinsic and intrinsic factors. 1. Extrinsic Risk Factors According to the National Pressure Ulcer Advisory Panel (NPUAP) a pressure ulcer is a localized injury to the skin and/or underlying tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction. 3 Pressure is the force per unit area exerted perpendicular to the plane of interest. 34 If the patient is lying or sitting in one position for extended periods of time, soft tissue overlying a boney prominence becomes compressed by external pressure, and may result in impeded blood flow, called ischemia. Tissues are then deprived of nutrients and oxygen, which can lead to cell death. 27 Friction is the resistance to motion in a parallel direction relative to the common boundary of two surfaces. 34 It is the force exerted when two surfaces in contact with each other move in opposite directions, such as when skin moves across the cover of a support surface. 35 10
Prevention, Care & Management Shear is trauma caused by tissue layers sliding against each other. Shear occurs when the outer surface of the skin remains stationary and the underlying boney structure moves with gravity, resulting in disruption or angulation of blood vessels. 27,35 The force per unit area exerted parallel to the plane of interest. 34 Extrinsic risk factors that place a patient at risk for pressure ulcers: 3,14,16,27 External pressure on the patient from an orthopedic device, tubing from medical devices such as IV s, catheters or oxygen, or from an inappropriate support surface Excessive exposure to moisture (i.e. incontinence, wound drainage, excessive perspiration) All surgical patients who are under anesthesia for extended periods of time 2. Intrinsic Risk Factors Intrinsic risk factors include: 3,27 Patients with certain medical conditions and co-morbidities that may impair healing such as diabetes, stroke, fractured hips Patients with impaired ability to sense and react to pain and discomfort Immobility, meaning the individual is chair or bed bound Impaired mobility to reposition Patients with altered levels of consciousness such as dementia Age over 65 the elderly develop thin, dry skin that bruises and injures easily, is less tolerant of heat, and allows for bony protrusions Body type, such as obesity or low body weight Infection, ischemia and anemia Immunosuppression Nutritional factors, such as inadequate dietary intakes or impaired nutritional status History of pressure ulcers Presence of current ulcers Surgical interventions that increase the risk for additional pressure ulcer Conditions contributing to friction or shear against the skin (i.e. patient unable to pull self up in bed, patient with involuntary muscle movements causing rubbing against sheets) Incorrect posture It is important to note that risk factors are seldom solitary and are frequently accompanied by other risk factors, making prevention and treatment strategies complex and interconnected. 36 B. Risk Assessment Tools One of the most important things clinicians can do to assess the level or risk for pressure ulcers and predict which patients are most likely to develop pressure ulcers is to use research-based validated risk assessment tools that are reliable and age appropriate. 14 The most extensively studied tools are the Braden 37 and Norton 38 scales. The Braden Scale has six subscales that measure sensory perception, moisture, activity, mobility, nutrition, friction, and shear. 37 The Norton Scale has five subscales that measure physical condition, mental state, activity, mobility, and incontinence. 38 These scales assess patients with the intent of ranking a patient from moderate to severe risk of pressure ulcers. Kimberly-Clark Health Care Education 11
Prevention, Care and Management The Braden and Norton scales are recommended for use by the AHCPR (now AHRQ) pressure ulcer prediction and prevention guidelines, 20 the Canadian Association of Wound Care Best Practices for the Prevention and Treatment of Pressure Ulcers, 39 the Clinical Practice Guideline for Pressure Ulcers published by the AMDA, 17 WOCN Guideline for Prevention and Management of Pressure Ulcers, 16 the IHI 5 Million Lives Campaign, 12 and The Joint Commission. 11 A study by Pancorbo-Hidalgo, Garcia-Fernandez, Lopez-Medica and Alvarez-Nieto investigating the clinical effectiveness of The Braden, Norton and Waterlow Scales concluded that the Braden Scale has the best validity (based on efficacy, balance of sensitivity and specificity) and reliability indicators across many studies and settings; and that both the Braden and Norton scales were better predictors of pressure ulcers than nurses clinical judgement. 40 The accuracy of assessment scales can vary according to setting; therefore, the use of the Braden or Norton scales must be supported by other assessment methods as part of a plan to identify major pressure ulcer risk factors and to develop a care plan to address risks. 39 If the use of the Braden or Norton scales is standardized across various healthcare institutions, consistency will be facilitated in prevention and practice by using valid and reliable measurement tools something that is lacking at this time in the United States and abroad according to research studies. 41,42,43 C. Assessing the Skin As the body s largest organ system, the skin may affect - or be affected by - other organs or body systems, and is a window into overall body function. 27 Skin assessments: 11,14,17,20 Must be conducted during the initial assessment Should be conducted at least daily in the acute care setting Should be conducted as a component of routine care Should be considered each and every time the patient is repositioned For example, a caregiver can do a complete assessment of the patient with the first shift encounter, and then reassess with each repositioning. As the patient is turned, the provider should examine the previous pressure points for signs of risk. Healthcare providers must make observation and diligent adherence to protocols a priority as they are key to prevention of pressure ulcers. To conduct a skin assessment: 14 Use adequate lighting to inspect and palpate skin over the sacrum, trochanters, ischium, heels, elbows and other boney prominences Observe the scalp, especially the back of the head, by parting the hair Inspect areas in contact or close proximity to medical devices or products such as oxygen or catheter tubing or compression stockings Inspect skin folds and creases in the obese population as the pressure of excess tissue against tissue (intertrigo) can increase risk for pressure ulcer development between these areas 44 The IHI Protecting 5 Million Lives from Harm Campaign suggests that a pressure ulcer admission assessment should include both a risk assessment and a skin assessment as a single process step. 12 12
D. Assessing the Wound Pressure Ulcers Prevention, Care & Management 1. Staging the Pressure Ulcer If an area of skin discoloration or a pressure ulcer is noted, you will need to thoroughly document a description in the patient s medical record. NOTE: It is important that healthcare professionals be able to differentiate between pressure ulcers and all other types of ulcers, as these have different etiologies, prognoses and treatment strategies. 17 Begin by describing the location of the pressure ulcer, and then classify it according to the NPUAPS 2007 Staging System as Suspected Deep Tissue Injury, Stage I, II, III or IV, or Unstageable according to the degree of tissue damage observed. 45 Although a number of staging systems have been developed over the years for the classification or staging of pressure ulcers, it is important to use an accurate and universally recognized system. For this reason, the WOCN supports the use of the NPUAP Staging System. 33 Suspected Deep Tissue Injury is a typically well demarcated purple or maroon area of discolored intact skin or blood-filled blister due to damage of underlying tissue from pressure and/or shear and may be difficult to detect in individuals with dark skin tones. The injury is not visible until it comes to the surface, and may be very deep, involving muscle and/or bone. 45 The suspected deep tissue injury area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. The area may develop a thin blood-filled blister over a dark wound bed, may further evolve and develop a covering of eschar, and may rapidly expose additional layers of tissue even with optimal treatment. 45 Stage I is defined as intact skin with non-blancheable redness of a localized area, usually over a boney prominence. 45 Stage I ulcers are not usually well demarcated and tend to be less bold in color as compared to Suspected Deep Tissue Injury. In darkly pigmented skin, rather than redness, the color may be different from the surrounding area. Stage I ulcers are also indicated by sensory changes such as pain, changes in skin temperature (warmer or cooler), and firm or soft tissue as compared to surrounding tissue. 45 A Stage I ulcer is considered a pre-ulcer and a heralding sign of a more extensive wound, and as such requires protection and frequent monitoring from further injury from shear, pressure and moisture. 17,45 NOTE: When assessing patients with darkly pigmented skin, practice cultural sensitivity. Consider using a halogen light to look for color changes. 19 Stage II is partial thickness loss of dermis that may present as a shallow open ulcer with a red or pink wound bed without slough, an intact or open serum-filled blister, or a shiny or dry shallow ulcer without slough. 45 Keep in mind that this stage should not be used to describe skin tears, peritoneal dermatitis, tape burns, maceration or excoriation. 45 Stage III is full thickness skin loss where 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; and there may be undermining and tunneling that makes the wound much larger than may seem on the surface. 45 The depth of a Stage III pressure ulcer varies by anatomical location. Areas of significant adiposity can develop a deep crater with or without undermining of adjacent tissue even if bone or tendon is not visible or directly palpable. 33 However, if the area does not have subcutaneous tissue such as the bridge of the nose, occiput and malleolus, Stage III ulcers can be shallow. 45 Kimberly-Clark Health Care Education 13
Prevention, Care and Management Stage IV pressure ulcers have full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed, and there is often undermining and tunneling. As with Stage III, the depth of a Stage IV ulcer will vary by anatomical location. Stage IV ulcers have exposed bone or tendon that is visible or directly palpable. Osteomyelitis is possible, and damage can extend into muscle and/or supporting structures such as tendon, fascia or joint capsule. 45 Wounds that are covered with eschar and/or slough cannot be staged. Therefore, while the wound is covered with eschar and/or slough, or until enough slough or eschar is removed to expose the base of the wound, the ulcer should be documented as Unstageable. 45 Document the size, location and appearance of the ulcer as well as the status of the surrounding tissue, and document Staging cannot be completed until the pressure ulcer base is visible. 33 Other Documentation Tips According to the WOCN, if the original depth of the pressure ulcer is unknown and it is resurfaced, the stage cannot be determined by observation. However, when contracted scar tissue is present and the pressure ulcer is resurfaced, the healed pressure ulcer should be described as evidence of a resurfaced full-thickness pressure ulcer or evidence of a resurfaced pressure ulcer of undetermined full thickness depth. 33 If a pressure ulcer is partially covered in necrotic tissue but has visible identifiable muscle, bone or supporting structures such as tendon or joint capsule, document the pressure ulcer as a Stage IV with necrotic tissue. This is based on the fact that the exposed tissue clearly meets the criteria for the most severe pressure ulcer stage. 33 On the other hand, if a pressure ulcer is partially covered with necrotic tissue and viable subcutaneous tissue is visible, the pressure ulcer base cannot be staged. This is because pressure ulcers only penetrating to the subcutaneous tissue are appropriately classified as Stage III. Debridement of the remaining necrotic tissue may reveal exposed muscle or bone, therefore indicating the true stage of the pressure ulcer as IV. 33 Since wound staging can often be a difficult task, please be sure to check with your facility s Wound Care experts to verify proper wound classification and documentation criteria. 2. Describing the Pressure Ulcer In addition to documenting the Stage, descriptors are needed to truly convey the state of the pressure ulcer. 33 Be sure to document the following: 17,22,33 The size, including the length, width, and depth of the pressure ulcer in centimeters The presence, location and depth of sinus tracts or undermining The condition of wound bed edges (closed and non-proliferative vs. open and proliferative) The color and type of tissue that comprise the ulcer bed The status of the pressure ulcer bed (granulating or epithelializing vs. clean but not granulating or avascular) The volume, color and odor of exudate Whether there is evidence of infection in surrounding tissue (erythema, induration, crepitance) Peripheral pulses when lower extremity ulcers are present 14
Prevention, Care & Management The following definitions from the text book Acute and Chronic Wounds Nursing Management may be helpful in understanding the above descriptors: 35 Sinus tract: (Also known as Tunneling) Course or pathway that can extend in any direction from the wound surface; results in dead space with potential for abscess formation. Undermining: Tissue destruction to underlying intact skin along wound margins. Granulation tissue: Formation or growth of small blood vessels and connective tissue in a full-thickness wound. Eschar: Thick, leathery necrotic tissue; devitalized tissue. Slough: Loose, stringy necrotic tissue. Full thickness wound: Tissue destruction extending through the dermis to involve the subcutaneous layer and possibly muscle and bone. Partial thickness wound: Loss of epidermis and possible partial loss of dermis. Infection: Overgrowth of microorganisms capable of tissue destruction and invasion, accompanied by local or systemic symptoms. Wound base: Uppermost viable tissue layer of the wound; may be covered with slough or eschar. If any non-healing conditions are present, be sure to consult with the appropriate health care professional so that the patient is treated properly and in a timely manner. 17 3. Measuring the Wound The NPUAP recommends that the dimensions of the pressure ulcer always be measured in centimeters in the order of length, width, and depth. 46 Length is the longest head-to-toe measurement Width is longest hip-to-hip measurement Depth is from the tip of the applicator to the level of the skin surface in the deepest part of the wound. Undermining and tunneling are measured as if the patient is on a clock, and the head is at 12 o clock. Undermining is measured from the extent of the undermining clockwise, and the deepest part of the undermining (i.e. 1.5cm from 2-7 o clock) Tunneling/Sinus tracts are measured from depth of sinus tract/tunnel and direction given in clock method (i.e. 3 cm at 3 o clock). If there are more than one sinus tract, number each clockwise. Here are other techniques for determining the length, width and depth of a pressure ulcer. 47 Linear measurement This traditional method involves measuring linear distance (length vs. width) using a tape measure or markings on a scalpel-handle ruler. The practitioner can trace the wound using two tracing sheets and discard the bottom sheet. Area measurement This calculates the wound in square centimeters (cm2) by multiplying 2 perpendicular linear dimensions. Volume/depth measurement The length of a wound tract can be determined by inserting a sterile cotton swab into the maximum wound depth and documented on the wound tracing. Volume can be calculated as area times depth, by inserting a molding material into the wound to reproduce its volume. 47 Kimberly-Clark Health Care Education 15
Prevention, Care and Management Visual Assessment and Documentation A visual assessment of the wound can help complete a qualitative assessment of the wound. Some facilities use a red/yellow/black system to document wound color, digital photography, or photogrammetry based on color and light-balanced computerized photographic image capture. 47 Some facilities find color photos taken during initial assessment and reassessments helpful in monitoring change. If color photos are taken during assessments, keep the following in mind for proper documentation :27,48 Take photos to support documentation, not replace it. Photos should be taken in compliance with a protocol that addresses how often the photos are taken, the type of equipment used, who can take the photos, and that ensure consistency in photographing. There should be a means to assure digital pictures are accurate and not modified. The photos should include information on the ulcer location, date etc. within the photo. Be careful to include identifying information such as initials, medical record number, and the date and time within the photo. Obtain informed consent from the patient or family. The Joint Commission strongly advises accredited facilities to obtain an informed consent prior to photographing the patient. Pictures or video footage taken without informed consent can be sequestered or not finalized as part of documentation until the appropriate consent is obtained. 49 HIPAA guidelines require that patients be adequately informed of the use of photography and how privacy will be protected. 49 E. The Nutritional Assessment Adequate dietary intake and hydration are essential for preventing the formation of pressure ulcers and enabling healing. As part of a nutritional risk assessment, consider the following: 14,16,17,22,50 Summarize the nutritional evidence such as the rate of weight loss and appetite decline Assess that the prescribed diet is consistent with the patient s requirements based on clinical status, activity level and preferences Identify any risk of hydration imbalance or deficit Check to see if dentures fit properly and teeth are in good condition Assess food consistencies in relation to the patient s ability to chew and swallow Identify conditions requiring enteral feeding, or physical barriers such as tremors, dysphagia, hemiparesis/plegia, bradykinesia, or uncoordination of fine and gross motor tasks that may prolong feeding time Document draining wounds that may require additional vitamins, minerals and protein Assess lab parameters to determine nutritional status which may include albumin or pre-albumin, transferring, and total lymphocyte count Weigh at-risk patients weekly Nutritional assessments should be performed upon admission, on a regular basis, and anytime there is a change in the individual s condition that may increase the risk of malnutrition. 16 16
F. The Pain Assessment Pressure Ulcers Prevention, Care & Management Pressure ulcers may be painful in all stages, and managing pain is often a top priority for patients. Therefore, conduct a pain assessment using a pain assessment tool that is not specific to wound care, and assess pain initially, with every dressing change, and during care and treatment to determine if there is pain related to the pressure ulcer or its treatment. 18,22 Assess the ability of the patient to sense and react to pain and discomfort. 17 The location, frequency and intensity of pain can be an important indicator of untreated underlying disease, the exposure of nerve endings, the efficacy of wound care, and whether psychological needs should be addressed. 22 G. The Psychosocial Assessment Conduct a psychosocial assessment initially and throughout treatment to determine: 17,22 Whether the patient understands the care plan, and is motivated to adhere to it The effect of the pressure ulcer on the patient s social and occupational status Quality of life from the patient s perspective If depression is present so that it may be treated The chronic pain, suffering and diminished quality of life due to pressure ulcers often lead to depression and affect self image. 17,22 Patients who are depressed are less likely to eat right or play an active role in their rehabilitation and treatment efforts. 18 An assessment may help determine the environment most conducive for healing, and interventions that will help the patient cope. 51 Be aware that in particular, symptoms of depression are common in older adults and may be a risk factor for poor outcomes. A study by the Division of General Internal Medicine and Health Care Research measured 15 symptoms of depression, health status and severity of illness in elderly patients upon admission and found that patients with more symptoms of depression were less likely to improve and more likely to deteriorate during and after hospitalization. 52 H. Operating Room Considerations Patients who are under anesthesia for extended periods of time are at risk of acquiring pressure ulcers. Therefore, it is important that clinicians assess for risk prior to surgery, intra-operatively, as well as post-operatively, and implement prevention techniques to reduce the incidence of pressure ulcers. 22,53 If the patient is to undergo surgery for operative care of a Stage III or IV ulcer, it will also be important to assess, optimize and treat the following factors pre-operatively: 54 Comorbid conditions Local wound infection Osteomyelitis Bowel regulation Nutritional status Be sure to fully document all assessment and re-assessments to ensure compliance with CMS, accreditation requirements, regulatory agencies, as well as hospital protocol; and to enable complete communication with the interprofessional team. Kimberly-Clark Health Care Education 17
Prevention, Care and Management V. Implement Prevention Protocols to Address Risk Factors Based on the assessment, an interprofessional team must develop an individualized care plan that is realistic and addresses all identified risk factors even in patients currently cared for under Advance Directives. The care plan must consider the individual s clinical condition, prognosis, and projected clinical course, and be consistent with the patient s wishes and preferences. For example, the patient may have co-morbid conditions that may contribute to risk, affect the healing process or alter functional independence. A plan of care should be created that reflects these conditions. 18 Stages III and IV require physician involvement as they are associated with high morbidity and mortality. In addition, according to the CMS IPPS regulation, all pressure ulcers now require physician involvement since without their assessment and documentation they will not be valid as Present On Admission (POA) Indicators. 26 The care plan should: 17,18 Follow evidence-based standards of care, relevant clinical practice guidelines and regulatory requirements Meet the needs and preferences of the individual Promote wound healing Prevent complications or deterioration of existing wounds Prevent additional skin breakdown Minimize the harmful effects of the wound on the patient s overall condition Improve quality of life and preventing suffering while improving the consistency of care across disciplines Identify management strategies for general problems such as malaise, as well as specific issues such as diarrhea or heart failure that may be contributing to or causing wound development or impeding wound healing Be sure to document in the patient s medical record all risk factors, planned interventions, and decisions not to intervene. 18 Care plans should be assessed at least weekly, and the patient frequently, for progress in each of the treatment goals. 16 If no risk factors are found, continue to periodically monitor the patient for the development of risk factors. 18 It is suggested that the patient be reassessed daily for risk, as changes in nutrition, incontinence and mobility may require caregivers to adjust the care plan to the changing needs of the patient. 12 Use multiple methods to visually communicate to all relevant staff if the patient is at risk for pressure ulcers, such as stickers on patient charts or on the door to the patient s room. By implementing a visual reminder, staff will hopefully be more diligent in assessment and management of the patient and more likely to follow through on all prevention strategies. 12 To achieve the best results, the interprofessional care plan should identify the expected outcomes and treatment goals. Treatment goals will generally fall into these categories: Protect tissue integrity Determine and manage the causes of moisture and incontinence Practice pressure redistribution Manage the wound bed effectively Promote the growth of healthy tissue Promptly identify and manage complications 18
Prevention, Care & Management Minimize pain Meet nutrition and hydration needs Meet psychosocial needs Promote activity and mobility While caring for the patient remember that no two wounds are alike, and no two patients respond in the same way. What works for one patient may not necessarily work for another. Treatment and care modalities that may have worked at the beginning of care may not work throughout the healing process. Therefore, modify care as needed to accommodate changes in the wound and in the needs of the patient. Marianne Charest, RN A. Protect Tissue Integrity Proper skin care is the first step in maintaining and improving tissue tolerance to pressure. Therefore, the care plan must individualize a skin care program that addresses protecting tissue integrity and preventing further trauma. 11,16,18,20 Following are important aspects of a skin care program based on various guidelines. Conduct at least daily skin inspection. 12,14,16 Inspections can occur whenever caring for the patient; for example, bathing, moving from one area to another or turning the patient. 12 Any changes in skin or skin integrity should be documented, as should all interventions. 16 Avoid massage over bony prominences as this may lead to deep tissue trauma. 14,16 Perform bathing at an identified frequency, and with the proper agents. 14,16,20 Use a mild cleansing agent for bathing and avoid hot water and excessive rubbing. 14 Minimize drying of the skin by moisturizing dry skin regularly. 12,14 Use creams or a thin film of cornstarch to protect the skin 24 and use moisturizers sparingly so the skin does not remain damp for extended periods of time. 17 In addition, temperature and humidity should be maintained at levels that minimize damage to the patient s skin. 24 B. Determine and Manage the Causes of Moisture and Incontinence Continuous exposure to moisture increases the risk for skin break down and infection by causing the skin to macerate. Therefore, determining and managing the causes of moisture, including incontinence, are vital to preventing pressure ulcers. 12,16,20 Excessive sweating may be due to fever from infection, medications or the environment, and may or may not be controllable. 55 Increasing the turning frequency during times of fever may help reduce moisture on skin that predisposes skin to injury. Urinary or fecal incontinence are major risk factors for the acquisition of pressure ulcers. 16,20,24 The causes of incontinence that are often reversible include urinary tract infection, confusion, medications, polyuria due to hypercalcemia or glycosuria, fecal impaction, and restricted mobility due to restraints. 24 Incontinence-associated dermatitis or IAD is inflammation of the skin that occurs when urine or stool comes into contact with perineal or perigenital skin and should not be confused with pressure ulcers. Both urine and feces contain substances that can irritate the skin and cause the skin to be up to 22 times more susceptible to skin breakdown than continent patients. 17,56 Research indicates 42.5% of incontinent patients have some type of Kimberly-Clark Health Care Education 19
Prevention, Care and Management skin injury that is preventable and increases the risk of pressure ulcers. 57 In addition, bladder and bowel incontinence can contaminate wounds. 17 Therefore, it is clear that prevention of IAD and management of incontinence are vital to the prevention of pressure ulcers. For patients with incontinence, establish a toileting program or offer the patient a bedpan in conjunction with a turning schedule. 6,7,63 If incontinence cannot be controlled, cleanse and dry the skin after each incontinent episode; and use absorbent pads to wick moisture away from the body such as polymer-filled underpads or moisture absorbing underwear that provide enhanced absorption and a quick drying surface to the skin. 14,16,20,50 A skin protectant or moisture barrier may also prevent tissue degradation and dermatitis, maintain and improve skin integrity, and significantly reduce the incidence of pressure ulcers. 50,58 However, whenever using skin protectants or moisture barriers, be sure the creams or ointments are compatible with the absorbent pads used. 55 A study by Clever, Smith, Bowser and Monroe found that the frequent application of a skin protectant in conjunction with a comprehensive pressure ulcer prevention program resulted in no sacral/buttock pressure ulcers occurring in patients with incontinence over a nine month period a 100% reduction. 59 If the severity of urinary incontinence has contributed to the creation of a pressure ulcer or may contaminate the pressure ulcer, an indwelling catheter may be indicated for a short period of time. 16 However, this must be considered carefully, as the use of indwelling urinary catheters have been associated with catheter-associated urinary tract infections. 60 C. Practice Pressure Redistribution Create a written positioning and turning schedule for at-risk patients and follow these schedules precisely. 14,20 Repositioning and turning are simple yet effective tools for the prevention and management of pressure ulcers, and are absolutely critical for patients who are immobile or dependent on staff for repositioning. AHRQ, WOCN, NPUAP and others recommend turning and positioning bed bound patients at least every two hours (with small turns in between the positional changes if at very high risk), if consistent with overall care goals. 12,14,20 However, keep in mind that patients who are at significant risk for pressure ulcers can develop them in less than two hours on a standard support surface. 32 Be sure to document when turning and positioning occurs, and update and modify the schedule as the patient s status changes. 18 Devices such as signs, clocks or chimes can be used to alert or remind caregivers to turn the patient. Proper techniques for turning and positioning should be reviewed with all staff and caregivers involved in the patient s care. 18 Take special care during repositioning to protect the skin of patients who are at risk for pressure ulcers. Use lifting devices such as a trapeze or nylon lifting sheet to move rather than drag patients during transfers and position changes in order to minimize friction and shear. 12,14,16,18,20 Friction and shear can also be reduced with the use of dry lubricants such as cornstarch, or the application of barrier films such as hydrocolloids or transparent films. 24 Select support surfaces that can alleviate or redistribute pressure, minimize the harmful effects of friction and shear, and manage moisture and heat based on the identified needs of the patient. 12,16,18,20 Another way to protect tissue integrity and prevent further trauma is to manage tissue loads by using appropriate support surfaces or devices. 18,20 Support surfaces should be selected according to the identified needs of the patient, and should consider the overall plan of care, transfers, caregiver impacts, mobility, ease of use, cost/ benefit, etc. 22 Choice of support surfaces should also take into consideration posture alignment, distribution of weight, balance and stability. 14 20