Pressure Ulcers- The Evidence in 2011

1. Pressure Ulcers- The Evidence in 2011 Ashley Shepherd, SN and Deborah Whittemore ANP, MSN,CWCN Husson University

2. Florence Nightingale 1859 • “If the patient has a bedsore, it is generally not the fault of the disease, but of the nursing”

3. The Definition has Changed • National Pressure Advisory Panel • 2007 • Represents five years of work • Changing definition affects focus of management • It’s not just pressure anymore

4. Pressure Ulcer Definition • Localized injury to the skin and/or underlying tissue • Usually over a bony prominence • Result of pressure or in combination with shear and/or friction • Significance of other factors unknown

5. Pressure Ulcer Stages • Revised by NPUAP in 2007 • First revision since 1975 • Represents five years of work • Adds two stages- deep tissue injury and unstageable • Critical that staff receive training and have written cues to assist with documentation • Has implications for reimbursement

6. Deep Tissue Injury • Purple or maroon localized area of intact skin • Blood filled blister • Due to damage of underlying soft tissue due to pressure and/or shear • May be preceded by tissue that is painful, mushy, boggy, warmer or cooler than adjacent tissue • May evolve rapidly even with RX • This used to be called a stage one pressure ulcer

7. Suspected Deep Tissue Injury

8. Unstageable • Full thickness skin loss • Covered by slough and/or eschar • Can’t stage until base is visible • Stable dry heel eschar should not be removed; relieve pressure by elevating off bed

9. Unstageable

10. Avoidable Versus Unavoidable WOCN 2009 • There are clinical circumstances in which a pressure ulcer is unavoidable • The burden of disease may overwhelm the skin which is the largest organ” • “unavoidable” means that ulcer developed despite appropriate risk screening and interventions • Prevention interventions may be inappropriate at end of life due to pain or undue family burden • Nurses need to be able to identify when wound requires palliative care even when patient is not terminal • There should be separate treatment protocols for palliative wound treatment • Physician, patient, and family need education

11. Risk Assessment • Use validated risk assessment tool i.e. Braden’s Scale in conjunction with skin assessment and clinical judgment http://www.bradenscale.com.braden.pdf • Research has shown that hospital nurses can accurately determine pressure ulcer risk 75.6% of time with the Braden Scale • Appropriate interval for reassessment remains unclear

12. Assessment of Other Risk Factors • More than 100 have been identified • Diagnoses such as diabetes, peripheral vascular disease, CVA, sepsis, hypotension, malignancy • Age 70 and over • Smoking • Dry skin • Low body mass index • Physical restraints

13. Implementing a Prevention Plan • Research has shown that using the AHRQ guidelines(1992/1994) on pressure ulcer prediction and prevention can lead to decreased incidence of pressure ulcers. • Were updated by the WOCN in 2003 and the Canadian Association of Wound Care in 2006

14. Local Wound Care • Clean with normal saline(expert opinion) • Maintain a moist wound environment • Absorb exudate • Manage bacterial burden • Protect the peri-wound from maceration • Change dressings as infrequently as possible • Debride when appropriate • Control odor when indicated

15. Wound Protocol • Need written guidelines for the management of wounds • Should be based on optimal wound care and cost of product • Use generics when possible • Provide staff training • Develop a Wound Formulary for your facility • This provides consistent, cost-effective evidence based care

16. Why Not Wet to Dry Normal Saline Dressings? • George Winter PHD in 1962 did research which demonstrated moist wound healing healed wounds in half the time • Wet to Dry causes pain and remove healthy tissue • Bacteria can migrate through 62 layers of gauze • Medicare requires moist wound healing for pressure ulcers in home care

17. Modern Wound Dressings • There are more than 300 different dressings available • Basic 7 classifications include transparent films, foams, hydrocolloids, alginates, hydrogels, and petroleum-based nonadherents • Most research on dressings compares the modern dressing to gauze so impossible to see which classification is better

18. What is the Evidence on Silver Dressings? • There have been 3 randomized clinical trials covering 847 participants. There remains insufficient evidence to recommend the use of silver-containing dressings or topical agents for treatment of infected or contaminated wounds

19. Adjunctive Therapies • Except for electrical stimulation there is minimal research supporting adjunctive therapies. E-stim should be considered for non healing pressure ulcers . • Few randomized controlled trials on negative pressure therapy. Emerging evidence that it may assist in healing pressure ulcers • Three small randomized controlled trials demonstrated improved healing with growth factors • No evidence for hyperbaric oxygen or ultrasound

20. Some Research Implications • Need to determine hierarchy of risk factors • Need to develop and validate newer pressure ulcer prediction tools • Need to study the effectiveness of support surfaces and determine optimal turning schedules • Nursing research is needed to determine best debridement methods • Need randomized controlled trials to determine optimal dressings within a classification.

21. Resources • Wound Ostomy Continence Nursing Society; www.WOCN.org • National Pressure Ulcer Advisory Panel www.NPUAP.org • Has Pressure Ulcer Prevention and Treatment Guides