PRESSURE ULCERS

1. PRESSURE ULCERS Kansas Reynolds Program in Aging Shelley B. Bhattacharya, D.O., M.P.H. Assistant Professor, Director of Geriatric Education Department of Family Medicine

2. 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

3. 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)

4. 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 >10% over 1 year or low albumin or prealbumin levels), THEN nutritional intervention or dietary consultation should be instituted

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

6. 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

7. 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

8. Pressure Ulcer Staging Source: http://www.medicaledu.com/staging.htm

9. 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

10. 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. Used with permission LWW

11. 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

12. 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

13. 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

14. PREVALENCE OF PRESSURE ULCERS VARIES BY SETTING 1% to 30% 3% to 30% 5% to 15% Source: GRS 6

15. PREVALENCE OF PRESSURE ULCERS VARIES BY STAGE Source: GRS 6

16. 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

17. 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 INTRINSIC FACTORS PREDICTIVE OF PRESSURE ULCER DEVELOPMENT

18. 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

19. 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 Source: http://www.nursingquality.org/NDNQIPressureUlcerTraining/module1/staging05.aspx

20. Any skin surface subject to excess pressure Examples include skin surfaces under: Oxygen tubing Urinary catheter drainage tubing Casts Cervical collars Other locations…

21. 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

22. RISK ASSESSMENT INSTRUMENTS Widely used tools for identifying older patients at risk for developing ulcers: SCREENING TOOLS • Norton scale: sensitivity =73%–92%, specificity = 61%–94% • Braden scale: sensitivity = 83%–100%, specificity = 64%–77% Both recommended by Agency for Healthcare Research and Quality

23. BRADEN SCALE Provides method for assessing a patient’s 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 • Friction and Shear

25. NORTON SCALE Provides method for assessing a patient’s pressure ulcer risk by evaluating: • Physical condition • Mental condition • Level of physical activity • Mobility • Continence or incontinence

26. 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.

27. PREVENTION An evidence-based approach to preventing pressure ulcers focuses on: Skin care Mechanical loading Support surfaces

28. 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

29. PREVENTION:MECHANICAL 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)

30. 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

31. 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

32. 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 <1 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

33. SUPPORT SURFACES

34. 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

35. Location Stage Area Depth Pain Drainage Necrosis Granulation Cellulitis MANAGEMENT: ULCER ASSESSMENTEvaluate and document the following:

36. MANAGEMENT:MONITORING 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)

37. PRESSURE ULCER SCALE FOR HEALING (PUSH) • A validated method to document healing over time • Observe and measure the ulcer’s: • 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

40. 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

41. MANAGEMENT:CONTROL 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

43. MANAGEMENT:CONTROL 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-Ray—Soft tissue swelling, bone destruction (10-21 d after infection) • CT—Medullary and cortical destruction • MRI—Better 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.

44. MRI views of osteomyelitis Courtesy: Lancet 2004 Jul 24;364(9431):369

45. 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

46. MANAGEMENT:METHODS OF DEBRIDEMENT

47. MANAGEMENT:DRESSINGS • Transparent film (Tegaderm):stage I, protects from friction Contraindicated: skin tears, draining, suspected infection • Foam island:stages II, III Contraindicated: excessive exudate; dry, crusted wound • Hydrocolloid (Duoderm):stages II, III Contraindicated: poor skin integrity, infection, wound needs packing • Petroleum-based nonadherent:stages II, III,graft sites

48. MANAGEMENT:DRESSINGS • Calcium Alginate (Tegaderm HI): stages II, III, IV, for excessive drainage Contraindicated in: dry or superficial wound with maceration • Hydrogel, amorphous (Curasol): stages II, III, IV; must combine with gauze dressing Contraindicated: maceration, excess exudate • Hydrogel, sheet (Nu-Gel): stage II, skin tears Contraindicated: maceration, moderate to heavy exudate • Gauze packing: stages III, IV, deep wounds

49. MANAGEMENT:NUTRITION • 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 poor pressure ulcer development and healing

50. Nutrition and Ulcers—the 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