Telephone-Based Training

Pressure Ulcer Management

Dial-In Information

Telephone Number: (888) 850-5066

Confirmation Code: 35193

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Pressure Ulcer Assessment and Management

Presented by:Beth Brizee, RN,CDirector of Clinical OperationsTriLine Medical888-966-6662 ext 301

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Pressure Ulcer Assessment and Management Objectives

By the end of the course participants will be able to:Classify pressure ulcers by stage and differentiate ulcers of non-pressure etiology.Discuss current treatment practices and interventions for pressure ulcer management.Review key documentation areas for the medical record management of pressure ulcers.

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Overview of the Layers of the SkinThe skin is comprised of three major components:

EpidermisDermisSubcutaneous tissue

Though interrelated, each layer of skin has different structures, cell types and functions

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What is a Pressure Ulcer?Localized areas of tissue necrosis which develop when soft tissue

is compressed between a bony prominence and an external surface for a prolonged period of time.

Unlike other ulcerations, which have a disease process associated with their development or decline, pressure ulcers have heightened requirements around: risk assessment; proactive and therapeutic care giver interventions; assessment of response to interventions and medical record management.

Most pressure ulcers occur over bony prominences, where combined with friction and shearing forces result in skin breakdown.

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Most common sites in bed-bound elderlySupine:

23% sacrococcygeal8% heels1% occiput; spine

Sitting:24% ischium3% elbows

Lateral:15% trochanter7% malleolus6% knee3% heels

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Classification of WoundsThe staging of pressure ulcers, as defined by national guidelines

(NPUAP, CMS, AHCPR), allow for common understandings for healthcare professionals. The staging of a pressure ulcer reflects the amount of tissue damage. Outside of the MDS, only pressure ulcers are staged – stage I – IV, UTD and DTI.

Any wound such as a pressure ulcer, neuropathic ulcer, etc., canbe considered “partial thickness” or “full thickness”depending upon the amount of tissue involved.

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Pressure Ulcers

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Stage I Pressure UlcerThe ulcer appears as a defined area of persistent red, blue, or

purple hues in lightly pigmented skin.In darker skin tones, the ulcer may appear with discoloration, warmth, edema, induration or hardness.

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Stage I Pressure Ulcer Treatment Options

Stage I on Heels –Ensure that heel(s) are floated at all times with frequent monitoring.

Stage I on Trunk of the Body –Manage incontinence, keeping area clean and dry. Use moisture barrier as needed.Off load area were pressure ulcer is – pressure reducing surfaces

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Stage II Pressure UlcerPartial thickness skin loss involving epidermis, dermis, or both.The ulcer is superficial and presents clinically as an abrasion,

blister, or shallow crater.

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Stage II Pressure Ulcer Treatment Options

Minimal Drainage –Cleanse with normal saline, apply hydrocolloid dressing every three days and prn soiling or dislodging. Monitor placement every day.Off load area were pressure ulcer is – pressure reducing or relieving surfaces.

Dry Wound Bed –Cleanse with normal saline, apply small amount of hydrogel and cover with dd every day.Off load area were pressure ulcer is – pressure reducing or relieving surfaces.

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Stage III Pressure UlcerFull thickness skin loss involving damage to or necrosis of

subcutaneous tissue that may extend down to, but not through, underlying fascia.

The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

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Stage III Pressure Ulcer Treatment Options

Heavy Drainage and Clean–Cleanse with normal saline, apply foam dressing every two days and prn soiling or dislodging. Monitor placement every day.Off load area were pressure ulcer is – pressure relieving surfaces –preferable a low air loss mattress replacement.

Presence of Slough –Cleanse with normal saline, apply Accuzyme and cover with dd every day.Use Foam dressing instead of dd for heavy drainage.Off load area were pressure ulcer is – pressure relieving surfaces.

Minimal Drainage and Clean Wound Bed –Cleanse with normal saline, apply small amount of hydrogel and cover with dd every day.Off load area were pressure ulcer is – pressure relieving surfaces.

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Stage IV Pressure UlcerFull 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 also may be present.

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Stage IV Pressure Ulcer Treatment Options

Heavy Drainage and Clean–Cleanse with normal saline, apply foam dressing every two days and prn soiling or dislodging. Monitor placement every day.Off load area were pressure ulcer is – pressure relieving surfaces –preferable a low air loss mattress replacement.

Presence of Slough –Cleanse with normal saline, apply Accuzyme and cover with dd every day.Use Foam dressing instead of dd for heavy drainage.Off load area were pressure ulcer is – pressure relieving surfaces –preferable a low air loss mattress replacement.

Minimal Drainage and Clean Wound Bed –Cleanse with normal saline, apply small amount of hydrogel and cover with dd every day.Off load area were pressure ulcer is – pressure relieving surfaces –.

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UTD (Unable to Determine Stage) Pressure UlcerWhen a pressure ulcer wound bed is covered with non-viable

tissue such as “slough” or “eschar” the pressure ulcer can not be staged as visualization of the amount of tissue damage / involvement is impossible.

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UTD Stage Pressure Ulcer Treatment Options

Note – intact eschar on the lower extremities (i.e. heels) should not be actively debrided but should have pressure managed – floating of the heels

Heavy Drainage and Clean–Cleanse with normal saline, apply foam dressing every two days and prn soiling or dislodging. Monitor placement every day.Off load area were pressure ulcer is – pressure relieving surfaces –preferable a low air loss mattress replacement.

Presence of Slough –Cleanse with normal saline, apply Accuzyme and cover with dd every day.Use Foam dressing instead of dd for heavy drainage.Off load area were pressure ulcer is – pressure relieving surfaces –preferable a low air loss mattress replacement.

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Deep Tissue InjuryThese wounds present as intact skin with dark purple shading

almost to black area usually within a reddened area of skin. This represents a pressure injury of an unknown depth so this wound cannot be staged – also known as “Purple Pressure Injury” or “Pre-Eruptive Full-Thickness Pressure Ulcer.”

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Causative Factors for the Development of Pressure Ulcers

Immobility or limited mobilityIncontinenceShearing and friction injuriesAdvanced ageMalnutrition or under-nutritionSignificant obesity or thinnessHistory of pressure ulcersDehydrationContracturesUse of orthotic devises or restraintsIssues of resident compliance

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Immobility and Pressure Ulcers – CMS StatementsSome statements around tissue load management from CMS:

“Repositioning is a common, effective intervention for an individual with a pressure ulcer or who is at risk of developing one.”

“Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning.”

“Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing.”

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Immobility and Pressure Ulcers – CMS Statements

“Depending on the individualized assessment, more frequent repositioning may be warranted for individuals who are at higher risk for pressure ulcer development or who show evidence (e.g., Stage I pressure ulcers) that repositioning at two hour intervals is inadequate.”

“Based upon an assessment including evidence of tissue tolerance while sitting (checking for Stage I ulcers as noted above), the resident may not tolerate sitting in a chair in the same position for one hour at a time and may require a more frequent position change.”

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Interventions for the Management of Immobility

Individualized re-positioning schedules with thorough communication of needs and expectationsUse of appropriate pressure relieving or reducing support surfacesFloat heels Keep sheets free from wrinklesAvoid raising the head of bed more than 30 degreesAs appropriate, perform active or passive range of motion exercises to relieve pressure and promote circulationAdjust or pad appliances, casts, or splints as needed to ensure a proper fit and to prevent pressure and impaired circulation

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Interventions for the Management of Incontinence

Implement as appropriate a bowel and bladder retraining programEnsure healthful hydration through adequate daily fluid intakeAssess environmental issues – accessibility, manual dexterity (how easily can the resident manipulate their clothing)Regular reminders to void with prompt response to toiletFiber rich diets Promote regular exerciseMaintain effective hygiene care, cleaning the perineal area frequently with use of a moisture barrier

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Shearing and FrictionShear -

The gravitational pull of the body downward while the skin stays stationary on the surface of bed or chair.This gravitational pull creates a change in the angle of capillaries.

Friction –Result from forces that tend to cause two opposing surfaces to slide and displace against each other.

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Shearing Injury

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Interventions for the Prevention ofShear and Friction Injuries

Assuring that individuals are being repositioned and that nursing staff understand:Use of proper transferring and positioning equipmentTeaming up to safely reposition residentsLimit HOB elevation

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Interventions for the Management of Malnutrition “Under-Nutrition”

RD assessment and recommendations – should be at least every month if a pressure ulcer is presentMonitoring intake and output with communication of any changes in patternsProvide needed dental careFollow prescribed diets – protein supplementation, thickened liquidsOffer liquids as appropriate at each care giving activityEncourage intakeMaintain accurate medical record information for MD and RD – weights and I/O’s

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Overview of General Treatment Interventions for Pressure UlcersGeneral considerations for the treatment of pressure ulcers:

Manage the moisture.Remove non-viable tissue.*

EnzymaticSharp debridementMechanical debridement

Tissue load management – never placing resident directly on an existing wound – use appropriate support surfaces.Protect the peri-wound tissue.

*Intact eschar on extremities should not be debrided in most cases

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Classification of Wounds –Federal Guideline StatementAt the time of the assessment, clinicians (physicians, advance

practice nurses, physician assistants, and certified wound care specialists, etc.) should document the clinical basis (for example, type of skin injury/ulcer, location, shape, ulcer edges and wound bed, condition of surrounding tissues) for any determination that an ulcer is not pressure related, especially if the injury/ulcer has characteristics consistent with a pressure ulcer, but is determined not to be one.”

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Arterial UlcerationsVenous Stasis UlcerationsNeuropathic Ulcerations

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Arterial UlcerationsCause – Inadequate circulation to the legs

Contributing Factors:Arteriosclerosis and atheroslerosisMicro thrombiSmokingElevated cholesterol and lipidsHypertensionDiabetes

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Arterial Ulcerations Clinical PresentationSmall, deep, punched out lesionsWell demarcated, smooth edgesOften contain necrotic tissue and / or pale wound bedsUlcers frequently appear on tips of toes or fingers and over phalangeal headsUlcers may also appear around heels and ankles, sides and plantar surface of the foot

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Treatment Interventions for Arterial UlcersThe only treatment for arterial ulcerations is surgical intervention,

re-establishing circulation. Many of our LTC residents are not surgical candidates. In this case make sure to have the MD document the fact that the benefits of vascular surgical intervention are out weighed by the risk of the procedure. It is also important to have the resident (if appropriate) and the family members understand this as well.

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Venous Stasis UlcerationsAffect 3.5% of the populationHave approximately 70% recurrence rateAnatomy and Physiology of Venous Stasis Ulcers

Incompetent, malfunctioning valves:Contribute to backflowResult in increased pressure within veinsAllow leakage of serum and blood cells into tissueCreate edemaPresents with hemosiderin stainingUlcerations

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Venous Stasis Ulcerations Clinical Presentation

SuperficialIrregular in shapeUsually not painful / sensitiveUsually occur on medial aspect of legBrawny edema, deep, ruddy red tissueLegs appear hard and wooden-likeOften heavily draining ulcers

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Treatment Interventions for Venous Stasis UlcersThe treatment for venous stasis ulcers is surgical repair of the

malfunctioning valves. As with arterial ulcerations, many of our LTC residents are not surgical candidates. In this case make sure to have the MD document the fact that the benefits of vascular surgical intervention are out weighed by the risk of the procedure. It is also important to have the resident (ifappropriate) and the family members understand this as well.

Also note, that it is very important to ensure that arterial insufficiency has been ruled out before elevating or applying compression therapy.

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Diabetic Neuropathic UlcerRequires that the resident be diagnosed with diabetes mellitus and have peripheral neuropathy.

The diabetic ulcer characteristically occurs on the foot, e.g., at mid-foot, at the ball of the foot over the metatarsal heads, or on the top of toes with Charcot deformity.

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Medical Record Documentation for

Wound Care

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Medical Record Risk Management for Pressure Ulcers

Unlike other ulcerations, which have a disease process associated with their development or decline, pressure ulcers have heightened requirements around: risk assessment; proactive and therapeutic care giver interventions; assessment of response to interventions and medical record management

Risk AssessmentMD notification / participation in plan of careActual and Potential care plansIDT interventions and notesTreatment records with response to interventions

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Assessment ParametersWounds need to have the following assessed:

Etiology – if not pressure then the MD should document as wellStage if pressureSize – length by width by depth and tunneling if presentWound bed tissue characteristicsPeriwound tissue characteristicsSigns and symptoms of infectionResponse to current interventions

It is imperative that all wounds be assessed:Immediately upon admissionAt least weeklyUpon change of wound status (improvement or decline)Upon discharge

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Miscellaneous Discussion Points on Wound Healing

“Healed” vs. “Re-surfaced”Tensile strength at end of proliferation phase and the remodeling phaseRegulatory risk of re-occurrenceAssessment of scar tissue

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Closing Questions and Comments

Quality Improvement Resources

Lumetrawww.Lumetra.com

Advancing Excellence Campaignhttp://www.nhqualitycampaign.org/

MedQICwww.medqic.org

Setting Targets – Achieving Results (STAR)

A password-protected Web site created for nursing homesView current performance trends for six Quality Measures (QMs):

High-risk pressure ulcersPost acute pressure ulcers Chronic care painPost acute painDepressionPhysical restraints

Set annual performance targets.Set your QM targets at www.nhqi-star.org.

To Get Your CEU Credit

Download the CEU Evaluation Form.

Go to www.lumetra.com/events. Scroll down and click on the link for the 02/15/07 – Pressure Ulcer Management teleconference to download the CEU evaluation form.

Complete the form.Legibly

Include License number.

Fax the completed form to (415) 677-2091.

A CEU certificate will be mailed to you.