Clinical Practice Guideline(CPG) for Pressure Ulcers

For Practitioners

What is a Pressure Ulcer?

Definition: A pressure ulcer is a localized injury to the skin or underlying tissue, usually over a bony prominence, that is a result of pressure or of pressure combined with shear or friction.

Reported prevalence rates have ranged from 2.3 percent to 28 percent and reported incidence rates from 2.2 percent to 23.9 percent

What is a Pressure Ulcer?

95% of pressure ulcers develop on the lower body (about 65% in the pelvic area and 30% in the lower extremities)

2-6 times greater mortality risk Effective pressure ulcer treatment best

achieved through interdisciplinary team approach

Guidelines for Pressure Ulcers

Recognition Diagnosis Prevention and Treatment Monitoring

Recognition Steps

Examine the patient’s skin thoroughly to identify existing pressure ulcers

Identify risk factors for developing pressure ulcers

Review records/resident interview to identify previous history of pressure ulcers

Ulcer Type Pathophysiology Location

Diabetic Peripheral neuropathy secondary to small or large vessel disease in chronic, uncontrolled diabetes

Usually lower extremities

Ischemic Reduction in blood flow to tissues caused by coronary artery disease, diabetes mellitus, hypertension, hyperlipidemia, peripheral arterial disease, or smoking

Usually distal lower extremitiesTips of toes

Pressure Unrelieved pressure resulting in damage to skin or underlying tissue

Usually over bony prominences (e.g., buttocks, elbows, heels, ischium, medial and lateral malleolus, sacrum, trochanters)

Venous Venous hypertension resulting fromincompetence of venous valves, post-

phlebitic syndrome, or venous insufficiency. Tend to be irregularly shaped

Usually lower leg region

Distinguishing Features of Common Types of Ulcers

F314 Surveyor Guidance: Risk Factors for Developing Pressure Ulcers

According to the surveyor guidance accompanying F314, the risk factors that increase a patient’s susceptibility to developing pressure ulcers, or that may impair the healing of an existing pressure ulcer, include but are not limited to the following:

Comorbid conditions (e.g., diabetes mellitus, end-stage renal disease, thyroid disease)

Drugs that may affect ulcer healing (e.g., steroids) Exposure of skin to urinary or fecal incontinence History of a healed Stage III or IV pressure ulcer Impaired diffuse or localized blood flow (e.g., generalized atherosclerosis,

lower-extremity arterial insufficiency)

F314 Surveyor Guidance: Risk Factors for Developing Pressure Ulcers Impaired or decreased mobility and

functional ability Increase in friction or shear Moderate to severe cognitive impairment Resident refusal of some aspects of care

and treatment Undernutrition, malnutrition, and hydration

deficits (Adapted from CMS, 2007)

Assessment

Assess the patient’s overall physical and psychosocial health and characterize the pressure ulcer

Identify factors that can affect ulcer treatment and healing

Identify priorities in managing the ulcer and the patient

Assessment

A pressure ulcer should be assessed in the context of the patient’s overall clinical, functional, and cognitive status.

Assess the status of each of the patient’s current medical conditions.

Assess the patient’s nutritional status, including dietary and fluid intake

Assess for the presence of medical conditions that may interfere with independent feeding or decrease overall oral intake

Assessment

In patients with lower-extremity ulcers, assess for the presence of coolness, delayed capillary refill, dusky discoloration, or pedal pulses. The ankle-brachial index, determined by Doppler arterial studies, may be helpful in determining whether a lower-extremity ulcer is caused by vascular insufficiency or by pressure.

Assess the patient’s bed and chair mobility and ability to sense and react to pain and discomfort.

Other Factors That Should Be Assessed in a Patient With a Pressure Ulcer

Comorbid conditions (e.g., anemia, congestive heart failure, diabetes, edema*, immune deficiency, malignancies, peripheral vascular disease, thyroid disease)

Complications (e.g., cellulitis, osteomyelitis) Pain Presence of: Contractures Dementia Depression Terminal illness

Staging of pressure ulcers

Suspected deep tissue injury Purple or maroon localized area of discolored intact skin or blood-filled blister

due to damage of underlying soft tissue from pressure and/or shear*. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.Further description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark ulcer bed. The ulcer may further evolve and become covered by thin eschar*. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

Stage I Intact skin with nonblanchable redness of a localized area, usually over a bony

prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk).

Staging of pressure ulcers

Stage II Partial thickness loss of dermis presenting as a shallow open

ulcer with a red pink ulcer bed, without slough*. May also present as an intact or open/ruptured serum-filled blister.Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration* or excoriation.Bruising indicates suspected deep tissue injury

Staging of pressure ulcers

Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone,

tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining* and tunneling*.Further description: The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers.Bone/tendon is not visible or directly palpable.

Staging of pressure ulcers

Stage IV Full thickness tissue loss with exposed bone, tendon or

muscle. Slough or eschar may be present on some parts of the ulcer bed. Often include undermining and tunneling.Further description: The depth of a Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule)making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

Staging of pressure ulcers

Unstageable Full thickness tissue loss in which the base of the

ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the ulcer bed.Further description: Until enough slough and/or eschar is removed to expose the base of the ulcer, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema* or fluctuance*) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.

National Pressure Ulcer Advisory Panel, 2007

Factors that can affect ulcer treatment and healing

Physiologic factors Functional factors Psychosocial factors Ethical considerations

Identify Priorities in managing the ulcer and the patient

Effective management of a pressure ulcer requires: Identification and treatment of causative factors when feasible, Identification and treatment of modifiable comorbid conditions, Provision of optimal nutritional support, Determination of the best topical care to facilitate ulcer healing, Prevention and management of infection* of the ulcer or adjacent

tissue, and Pain control related to the ulcer and any comorbid conditions.

Prevention and Treatment

Pressure Ulcer Prevention Measures Create a turning and positioning schedule that is based on the

patient’s individual risk factors Do not massage reddened areas over bony prominences Evaluate and manage urinary and fecal incontinence Initiate a plan to prevent or manage a contracture Inspect skin during bathing or daily personal care Maintain adequate nutrition and hydration if possible Maintain the lowest possible head elevation to reduce the impact of

shear Position the patient to minimize pressure over bony prominences

and shearing forces over the heels and elbows, base of head, and ears

Use appropriate offloading or pressure-redistribution devices Use lifting devices such as draw sheets or a trapeze Use proper transferring techniques

Unavoidable Pressure Ulcers

Under the surveyor guidance accompanying F314, an unavoidable pressure ulcer is a pressure ulcer that develops even though a facility has done the following:

Evaluated the patient’s clinical condition and risk factors;

Defined and implemented interventions consistent with patient needs, goals, and recognized standards of practice;

Monitored and evaluated the impact of these interventions; and

Revised the approaches as appropriate

The following clinical circumstances, among others, may impede or prevent healing or result in additional ulcer development that may be unavoidable:

Cachexia, Metastatic cancer, Multiple organ failure, Sarcopenia, Severe vascular compromise, and Terminal illness.

Unavoidable Pressure Ulcers

Nutrition

Increased protein intake is often emphasized in patients with nonhealing wounds; adequate intake of any single nutrient, however, does not prevent pressure ulcer formation or facilitate healing.

Many clinicians recommend caloric intake of 30 kcal/kg to 35 kcal/kg33 and daily protein intake of 1.2 to 1.5 g/kg of body weight34 for nutritionally compromised patients who have or are at risk of pressure ulcers

Pain Management

Pain management. After assessing pain and defining its characteristics (e.g., frequency, intensity, possible aggravating factors) and causes, treat it aggressively by using appropriate pain management protocols. (See AMDA’s 2003 clinical practice guideline, Pain Management in the Long-Term Care Setting

Turning and Positioning

Proper positioning, turning, and transferring techniques are important to manage pressure and shearing forces, ensure weight redistribution on support surfaces, and protect uninvolved skin. Evidence does not support any specific time interval for turning patients as a preventive or healing strategy for pressure ulcers

Manage Pressure

A systematic review of support surfaces for pressure ulcer prevention found that the use of ordinary foam mattresses (less than 4 inches thick) presented a higher risk of pressure ulcer development than the use of higher-specification mattresses.45 Patients at risk of skin breakdown should be placed on a static support surface (e.g., foam overlay, foam mattress, static flotation device) rather than on a standard mattress.

Necrotic Tissue

Pressure ulcer healing may be delayed by the presence of necrotic tissue, which also provides a medium for bacterial growth. Any necrotic tissue observed during assessment of the ulcer should be debrided, provided that this intervention is consistent with overall patient care goals.

Debridement of an ulcer

When choosing a debridement method, consider Ulcer size, Amount of slough and exudate, Presence and severity of pain associated either with the ulcer or

with the method of debridement, Feasibility of performing sharp or surgical debridement, and Risks of transporting the patient outside of the facility vs. the

benefits of surgical debridement.

Heel Ulcers

It is generally recommended not to debride heel ulcers with dry, hard eschar unless there is edema, erythema, fluctuance, or drainage. Monitor heel ulcers closely for evidence of infection, at which time debridement should occur.

Cleaning the wound

An effective antiseptic should: Act quickly; Be nonirritating; Be nontoxic to viable tissue; Have a broad spectrum of activity; Have low resistance potential; and Work in the presence of blood, fibrin, pus, and

slough

Ulcer Dressings

The goals of dressing an ulcer are to: Keep the ulcer bed moist and the surrounding

skin dry, Protect the ulcer from contamination, and Promote healing.

Factors to Consider When Selecting Ulcer Care Products Burden to patient (i.e., number of daily dressing

changes required) Cost-effectiveness of product Costs of ancillary supplies and equipment

associated with treatment Ease of use and cost of staff time to use the product Safety, efficacy, and likelihood and potential severity

of complications Ulcer characteristics (e.g., depth, condition of

surrounding skin, location near sources of contamination, presence and amount of exudate)

F314 Surveyor Guidance: Monitoring Considerations Daily Monitoring Evaluate ulcer if no dressing is present Evaluate status of dressing if present: Is dressing

intact? Is drainage present? If so, is it leaking? Status of area surrounding ulcer that can be

observed without removing the dressing Presence of possible complications (e.g., signs of

increasing area of ulceration, soft tissue infection) Evaluate whether pain, if present, is adequately

controlled Document when a change or complication is

identified

F314 Surveyor Guidance: Monitoring Considerations Weekly or Dressing Change Monitoring Location and staging of ulcer Size (perpendicular measurement of greatest extent of length and width

of ulceration); depth; and presence, location, and extent of undermining, tunneling, or sinus tract*

Presence of exudate; if present, type (e.g., purulent, serous), color, odor, approximate amount

Presence of pain; if present, nature and frequency (e.g., episodic, continuous)

Status of wound bed: color and type of tissue; evidence of healing (e.g., granulation tissue); necrosis (slough, eschar)

Description of wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration)

F314 Surveyor Guidance: Monitoring Considerations Use of Photography in Pressure Ulcer Monitoring Photography may be used in monitoring as part of the facility’s

compliance efforts, if the facility has developed a protocol consistent with accepted standards, which include the following:

Frequency of use Photos taken at a consistent distance from the wound Type of photographic equipment used Means to ensure that digital images are accurate and not modified Inclusion of resident identification, ulcer location, dates, etc., within the

photographic image Parameters for comparison over time

IMPORTANT!

It is important to establish goals consistent with the values and lifestyle of the individual and his/her family.