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PressureUlcers

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Information about PressureUlcers
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Published on June 21, 2008

Author: drmdarif

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PRESSURE ULCERS : 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 OBJECTIVES : 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 ACOVE INDICATOR : 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) ACOVE INDICATOR : 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 TOPICS COVERED : TOPICS COVERED Epidemiology Complications Risk Factors and Risk Assessment Evidence based review of prevention techniques Ulcer Assessment and 2007 Staging definitions Monitoring and Treatment PRESSURE ULCER: DEFINITION : 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 PRESSURE ULCERS: A MAJOR ISSUE IN GERIATRIC MEDICINE : 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 Pressure Ulcer Staging : Pressure Ulcer Staging 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. STAGING OF PRESSURE ULCERS Used with permission EPUAP STAGING OF PRESSURE ULCERS : 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. STAGING OF PRESSURE ULCERS : 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. Used with permission LWW The right sacral ulcer extends into subcutaneous tissue. No muscle, bone, or tendon is visible. STAGING OF PRESSURE ULCERS : 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 STAGING OF PRESSURE ULCERS : 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 PREVALENCE OF PRESSURE ULCERS VARIES BY SETTING : PREVALENCE OF PRESSURE ULCERS VARIES BY SETTING 1% to 30% 3% to 30% 5% to 15% PREVALENCE OF PRESSURE ULCERS VARIES BY STAGE : PREVALENCE OF PRESSURE ULCERS VARIES BY STAGE RISK FACTORS : 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 INTRINSIC FACTORS PREDICTIVE OF PRESSURE ULCER DEVELOPMENT : 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 EXTRINSIC FACTORS PREDICTIVE OF PRESSURE ULCER DEVELOPMENT : 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 Usual pressure ulcer locations : 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 Other locations… : Other locations… Any skin surface subject to excess pressure Examples include skin surfaces under: Oxygen tubing Urinary catheter drainage tubing Casts Cervical collars POSSIBLE COMPLICATIONS : 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 RISK ASSESSMENT INSTRUMENTS : 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 BRADEN SCALE : 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 NORTON SCALE : 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 Scale Documentation Frequency : 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. PREVENTION : PREVENTION An evidence-based approach to preventing pressure ulcers focuses on: Skin care Mechanical loading Support surfaces PREVENTION: SKIN CARE : 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 PREVENTION:MECHANICAL LOADING : 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) Heel Ulcers : Heel Ulcers PREVENTING HEEL ULCERS : 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 PREVENTING HEEL ULCERS : 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 PRESSURE-REDUCINGSUPPORT SURFACES : 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 SUPPORT SURFACES : SUPPORT SURFACES MANAGEMENT: GENERAL ASSESSMENT : 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 MANAGEMENT: ULCER ASSESSMENTEvaluate and document the following: : MANAGEMENT: ULCER ASSESSMENTEvaluate and document the following: Location Stage Area Depth Pain Drainage Necrosis Granulation Cellulitis MANAGEMENT:MONITORING HEALING : 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) 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 PRESSURE ULCER SCALE FOR HEALING (PUSH) Evidence for Wound Assessments : 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 MANAGEMENT:CONTROL OF INFECTIONS : 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 MANAGEMENT:CONTROL OF INFECTIONS : 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. Slide 45: MRI views of osteomyelitis Courtesy: Lancet 2004 Jul 24;364(9431):369 Bacterial Culture Collection : 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 MANAGEMENT:METHODS OF DEBRIDEMENT : MANAGEMENT:METHODS OF DEBRIDEMENT MANAGEMENT:DRESSINGS : MANAGEMENT:DRESSINGS 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 MANAGEMENT:DRESSINGS : MANAGEMENT:DRESSINGS 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 MANAGEMENT:NUTRITION : 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 pressure ulcer development and healing Nutrition and Ulcers—the evidence! : 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 MANAGEMENT:SURGICAL REPAIR : MANAGEMENT:SURGICAL 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 MANAGEMENT:ADJUNCTIVE THERAPIES : MANAGEMENT:ADJUNCTIVE 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 SUMMARY : 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 CASE 1 (1 of 2) : 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). CASE 1 (2 of 2) : 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). CASE 2 (1 of 3) : CASE 2 (1 of 3) Your colleague’s 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. CASE 2 (2 of 3) : 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 CASE 2 (3 of 3) : 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 CASE 3 (1 of 3) : 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. CASE 3 (2 of 3) : 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 CASE 3 (3 of 3) : 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 References : 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: 55:S409-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. References : References http://www.nursingquality.org/NDNQIPressureUlcerTraining/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 24;364(9431):369

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