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

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 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 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

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

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

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

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

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

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

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

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

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Hospital Home Care Nursing Home

PREVALENCE OF PRESSURE ULCERS VARIES BY SETTING

1% to 30%3% to 30%

5% to 15%

PREVALENCE OF PRESSURE ULCERS VARIES BY STAGE

Stages III & IV, 20%

Stage I, 47%

Stage II, 33%

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

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

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 Over Bony Prominences

1. Occiput 2. Ears 3. Scapula 4. Spinous Processes 5. Shoulder 6. Elbow 7. Iliac Crest 8. Sacrum/Coccyx 9. Ischial Tuberosity 10. Trochanter 11. Knee 12. Malleolus 13. Heel 14. Toes

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

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

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

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

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 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

An evidence-based approach to preventing pressure ulcers focuses on:

Skin care

Mechanical loading

Support surfaces

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

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

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

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

**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

Surface

Moist

Heat

Shear

Pressure

Static: foam $ no no no yes

Static: flotation $ no no yes yes

Dynamic:

air-fluidized $$$

yes yes yes yes

Dynamic:

low-air-loss $$$

yes yes ? yes

Dynamic: alternating air $$

no no yes yes

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 ASSESSMENT

Evaluate and document the following:

Location Stage Area Depth Pain

Drainage Necrosis Granulation Cellulitis

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)

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

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

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

TOPICAL AGENT S. Aureus Strep Pseudomonas

Iodine (Iodosorb) x* x xGentamycin sulfate cream/ointment

x x x

Metronidazole gel/cream – works against anaerobes

Mupiricin 2% cream/ointment

x* x

Polymyxin B sulfate x* x xPolymyxin B sulfate, Bacitracin zinc, Neomycin

x x x

Silver sulfadiazine x* x xIonized Silver x* x x

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.

MRI views of osteomyelitis

Courtesy: Lancet 2004 Jul 24;364(9431):369

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

Type Methods Comments

Mechanical Wet-to-dry irrigation, hydrotherapy

May remove both dead & live tissue; may be painful

Surgical, sharp Scalpel, scissor to remove dead tissue; laser debridement

Quick, effective; use for infection; pain management needed

Enzymatic

(Accuzyme)

Topical agent to dissolve dead tissue

Use if no infection; may damage skin

Autolytic

(Duoderm)

Biosurgery

Allows dead tissue to self-digest

Larvae to digest dead tissue

Use if other methods not tolerated & no infection; effect delayed

Quick, effective, good if surgical debridement not an option

MANAGEMENT:DRESSINGS

Transparent film: stage I, protects from friction

Contraindicated: skin tears, draining, suspected infection

Foam island: stages II, IIIContraindicated: 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

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

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! 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

May be used for stage III and IV ulcersDirect 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

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

Technology Description Approved Indications

Comments

Apligraf Human skin equivalent Resistant venous leg ulcers, refractory diabetic neuropathic foot ulcers

Expensive; best for wounds >1 year old; 5 day shelf-life

Dermagraft Human skin equivalent DM neuropathic foot ulcers; venous ulcers (pending)

Expensive; 6 month shelf life (-70 degree freezer)

Regranex Recombinant PDGF in a hydrogel

Full thickness DM neuropathic foot ulcers w/adequate blood supply and no infection

Effectiveness limited by fact that infxn may not be clinically apparent; not reimbursed by Medicare

Platelet-Rich Plasma

(PRP)

Derived from pt’s blood; activated w/thrombin; gel form; apply immediately after prep

Acute and chronic wounds; may be applied as part of a surgical procedure

Left in place for 3-7 days; may require repeat applications usually every other week

Oasis Freeze-dried porcine small intestine submucosa

Acute and non-healing wounds

Selective for patients refractory to appropriate wound care; easy use; inexpensive; usually reimbursed

Technology Description Approved Indications

Comments

V.A.C. Negative pressure in a closed dressing system

Highly exudative wounds Removes excess interstitial fluid; can tx multiple wound sites; reduced frequency of dressing changes

Mini-V.A.C. Allows for ambulatory activities

For small wounds Facilitates ambulation an ADLs

Warm-up Heat-assisted occlusive dressing

Resistant or painful wounds

O2 transport enhanced by local heat

Hyaluronic Acid Ester of hyaluronic acid Hard to heal wounds with chronic inflammation

Easy use; inexpensive; need bacterial balance for optimal tx

Electrical Stimulation High voltage electrical stimulation

Pressure ulcers Effective in non-healing wounds?

Ultrasound Mechanical vibration Pressure ulcers Effective in non-healing wounds?

Hyperbaric oxygen (HBO) therapy

Systemic delivery of O2 in chambers at 2-3 times atmospheric pressure while breathing 100% O2

Necrotizing soft tissue infxn; gas gangrene; refractory osteomyelitis; thermal burns; radiation damage; compromised skin grafts and flaps

Expensive; specialized training/equipment; limited availability

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

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 http://www.nursingquality.org/NDNQIPressureUlcerTrain

ing/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