Pressure Ulcers – Prevention And Treatment

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Pressure ulcers – prevention and treatmentA Coloplast quick guide

Table of ContentsPressure ulcers – prevention and treatment. 3What is a pressure ulcer?. 4How do pressure ulcers occur?. 5Who develops pressure ulcers?. 6Prevalence of pressure ulcers. 7Risk factors. 8The Braden scale for predicting pressure ulcer risk. 9The Braden scale. 10Prevention of pressure ulcers. 11International NPUAP-EPUAPpressure ulcer classification system. 12Treatment of pressure ulcers. 18Wound infection. 20Wound debridement. 22Dressing selection. 24Coloplast solutions for pressure ulcers. 26Biatain – The simple choice for superior absorption. 30Other Coloplast products for pressure ulcers. 31References. 342

Pressure ulcers– prevention and treatmentAccording to recent literature, hospitalizations related to pressureulcers cost between 9.1 to 11.6 billion per year. The cost ofindividual patient care per pressure ulcer may range from 20,900 to 151,700. In 2007, Medicare estimated that eachpressure ulcer added an additional 43,180 in costs to a hospitalstay.¹ Understanding the challenges pressure ulcers present tothe patient and health system, education regarding theirprevention and treatment is increasingly important. All providersand care-givers involved in the continuum of patient care shouldhave access to tools which provide general knowledge on howto effectively tackle this condition.In an effort to support your health system’s goals on providingeducation on pressure ulcer prevention and treatment, Coloplasthas published this quick-guide. This guide is intended foreducational and informational purposes only. It contains keyrecommendations for the prevention and treatment of pressureulcers, and will be helpful to health care professionals who arenot dealing with pressure ulcers on a day-to-day basis.For further information on this topic, please refer to the Wound,Ostomy, Continence Nurses Society (wocn.org) for their“Guideline for Prevention and Management of Pressure Ulcers”and the NPUAP/EPUAP (npuap.org) for their “Pressure UlcerPrevention & Treatment: Clinical Practice Guideline”. Useful toolsfor pressure ulcer prevention are also available at the Bradenscale website (www.bradenscale.com)Coloplast Corp., April 2012.3

What is a pressure ulcer?International NPUAP-EPUAP pressure ulcer definition:A pressure ulcer is a localized injury to the skinand/or underlying tissue usually over a bonyprominence, as a result of pressure, orpressure in combination with shear.2Pressure ulcers are a major cause of morbidity and mortality, especially for persons with impaired sensation, prolonged immobility,or advanced age.Coccyx, Stage IIIKnee, Stage IVNPUAP copyright & used with permissionNPUAP copyright & used with permission4

How do pressureulcers occur?A pressure ulcer is the result of a degenerative change caused bybiological tissue (skin and underlying tissue) being exposed to pressureand shear forces. The increased pressure prevents the blood fromcirculating properly, and causes cell death, tissue necrosis and thedevelopment of pressure ulcers.Heel, UnstageableCoccyx, Stage IVNPUAP copyright & used with permissionNPUAP copyright & used with permissionThe effect of pressure and shear forces on tissue and blood supplyWithout loadPressureShear forces5

Who developspressure ulcers?Anyone is at-risk for the development of a pressure ulcer, but someare more likely to develop one than others. This is particularly true forthose with impaired sensation, prolonged immobility and advancedage.Whether young or old, if somebody with frail skin remains in oneposition for too long without shifting their weight, they are at-risk forpressure ulcers. Wheelchair users or people confined to a bed (forexample, after surgery or an injury), are especially at-risk and thosepeople who have a pressure ulcer are at an even greater risk fordeveloping another pressure ulcer.The most common sites for pressure ulcers to occur are over a bonyprominence, such as the buttock (sacrum/ischium), heels, hips(trochanter), elbows, ankles (lateral and medial malleolus), back,shoulders, back of the head (occipit) and ears.Common sites of pressure ulcers6

Prevalence ofpressure ulcersNational prevalence studies have been conducted in several countries.Prevalence studies, among patients in acute care hospitals, indicateda pressure ulcer prevalence ranging from 10.1% to 17%.3 Recently,5947 patients were surveyed in 25 hospitals in five Europeancountries. The pressure ulcer prevalence (Stage 1–4) was 18.1%. IfStage 1 pressure ulcers were excluded, the prevalence was 10.5%.The sacrum and heels were the most affected sites. Only 9.7% of thepatients in need of prevention received fully adequate preventativecare.3Vertebrae, UnstageableButtocks, Stage IINPUAP copyright & used with permissionNPUAP copyright & used with permissionButtocks, Stage IHeel, Stage IIINPUAP copyright & used with permissionNPUAP copyright & used with permission7

Risk factorsThe following factors increase the risk for pressure ulcers4· Bed or chair-bound· Advanced age ( 65 years)· Unable to move body or parts of body without help· Chronic conditions, such as diabetes or vascular disease, whichaffect perfusion (blood circulation)· Mental disability from conditions such as dementia· History of previous ulcer· Urinary and/or fecal incontinence· Inadequate/poor nutrition and/or dehydration· Diastolic pressure 60 and/or hemodynamic instabilityThe NPUAP/EPUAP pressure ulcer prevention and treatmentguidelines recommend to use a structured approach for riskassessment to identify individuals at-risk of developing pressureulcers. One of the most widely used risk assessment tools is theBraden Scale for Predicting Pressure Sore Risk , developed byBarbara Braden, PhD, RN and Nancy Bergstrom, PhD, RN, FAAN(bradenscale.com).NPUAP copyright & used with permission8

The Braden scalefor predictingpressure ulcer riskThe Braden scale is a clinically validated tool that allows nurses andother h ealthcare providers to reliably score a person’s level of risk for developing pressure ulcers by assessing six subscales:5· Sensory Perception – ability to respond meaningfully to pressure-related discomfort (1–4)· Moisture – degree to which skin is exposed to moisture (1–4)· Activity – degree of physical activity (1–4)· Mobility – ability to change and control body position (1–4)· Nutrition – usual food intake pattern (1–4)· Friction and Shear – amount of assistance needed to move, degree of sliding in bed and/or chair (1–3)Each of these subscales contains a numerical range, with one beingthe lowest score possible. The Braden scale score is then derivedfrom totaling the numerical rating from each subscale. The lowestpossible total score is 6 and the highest is 23. The lower the score,the higher the risk of developing pressure ulcers. Individuals withscores of 15-18 are considered at-risk of developing pressure ulcers ifother major risk factors are present; 13-14, moderate risk; 10-12, highrisk, and 9 or below, very high risk.5The Braden scale should always be used in conjunction with nursingjudgment. Each subscale score serves as a flag for assessments thatneed to be explored further, and a guide to the types of interventionsthat may be required. The lower the subscale scores and total score,the more ‘intense’ the nursing interventions should become.6Disclaimer:These are general guidelines. There may be specific pressure ulcer assessment tools used at your healthcare facility which must be followed.9

The Braden scaleThe cornerstone of pressure ulcer prevention is identifying andminimizing risk factors with the use of a validated risk assessment tool.10

Prevention ofpressure ulcersA person that is bed bound or cannot move due to paralysis, or whohas diabetes, vascular disease (circulation problems), incontinence,or mental disabilities, should be frequently checked for pressureulcers. Special attention should be paid to the areas over a bonyprominence where pressure ulcers often form.Look for reddened areas that, when pressed, do not blanch (turnwhite), or purple/maroon areas of intact skin. Also look for blisters,ulcers or other open areas.Interventions7· Schedule regular repositioning and turning for bed and chair-boundpatients· Utilize support surfaces on bed and chairs· Position with pillows or wedges between bony prominences· Elevate heels off bed· Gently cleanse skin at each time of soiling with pH-balanced,non-rinse skin cleanser· Apply a protective moisture barrier ointment to the affected area· Manage moisture due to perspiration with wicking, translocatingtextile with silver8 (InterDry Ag)· Offer active or passive range of motion exercises· Use lift sheets or lift equipment to reposition or transfer patient· Maintain head of bed at/or below 30-degrees, if consistent withpatient’s medical condition· Refer to dietitian for nutritional assessment and interventions· Report weight loss, poor appetite or gastrointestinal changes thatinterfere with eating· Assist with meals, as needed· Apply moisturizer to skin at least daily and PRN11

International NPUAPEPUAP pressure ulcerclassification systemCategory/Stage I:Heel, Stage INPUAP copyright & used withpermission12Non-blanchable redness of intact skinIntact skin with non-blanchable erythemaof a localized area usually over a bonyprominence. Discoloration of the skin,warmth, edema, hardness or pain mayalso be present. Darkly pigmented skinmay not have visible blanching.Further description: The area may bepainful, firm, soft, warmer or cooler ascompared to adjacent tissue. Category/Stage I may be difficult to detect inindividuals with dark skin tones. Mayindicate ‘at-risk’ persons.

International NPUAPEPUAP pressure ulcerclassification systemCategory/Stage II:Buttocks, Stage IINPUAP copyright & used withpermissionPartial thickness skin loss or blisterPartial thickness loss of dermis presentingas a shallow open ulcer with a red-pinkwound bed, without slough. May alsopresent as an intact or open/rupturedserum-filled or sero-sanginous filled blister.Further description: Presents as a shinyor dry shallow ulcer without slough orbruising. This category/stage should notbe used to describe skin tears, tape burns,incontinence-associated dermatitis,maceration or excoriation.13

International NPUAPEPUAP pressure ulcerclassification systemCategory/Stage III:Ischium, Stage IIINPUAP copyright & used withpermission14Full thickness skin loss (fat visible)Full thickness tissue loss. Subcutaneousfat may be visible but bone, tendon ormuscle are not exposed. Some sloughmay be present. May include underminingand tunnelling.Further description: The depth of aCategory/Stage III pressure ulcer varies byanatomical location. The bridge of thenose, ear, occiput and malleolus do nothave (adipose) subcutaneous tissue andCategory/Stage III ulcers can be shallow. Incontrast, areas of significant adiposity candevelop extremely deep Category/Stage IIIpressure ulcers. Bone/tendon is not visibleor directly palpable.

International NPUAPEPUAP pressure ulcerclassification systemCategory/Stage IV:Coccyx, Stage IVNPUAP copyright & used withpermissionFull thickness tissue loss(muscle/bone visible)Full thickness tissue loss with exposedbone, tendon or muscle. Slough oreschar may be present. Often includesundermining and tunneling.Further description: The depth of aCategory/Stage IV pressure ulcer variesby anatomical location. The bridge of thenose, ear, occiput and malleolus do nothave (adipose) subcutaneous tissue andthese ulcers can be shallow. Category/Stage IV ulcers can extend into muscleand/or supporting structures (forexample, fascia, tendon or joint capsule)making osteomyelitis or osteitis likely tooccur. Exposed bone/muscle is visible ordirectly palpable.15

International NPUAPEPUAP pressure ulcerclassification systemUnstageable:Hip, UnstageableNPUAP copyright & used withpermission16Full thickness skin loss - depthunknownFull thickness tissue loss in which actualdepth of the ulcer is completely obscuredby slough (yellow, tan, gray, green or brown)and/or eschar (tan, brown or black) in thewound bed.Further description: Until enough sloughand/or eschar are removed to expose thebase of the wound, the true depth cannotbe determined; but it will be either aCategory/Stage III or IV. Stable (dry,adherent, intact without erythema orfluctuance) eschar on the heels serves as“the body’s natural (biological) cover” andshould not be removed.

International NPUAPEPUAP pressure ulcerclassification systemSuspected DeepTissue Injury:Foot, SDTINPUAP copyright & used withpermissionDepth unknownPurple or maroon localized area ofdiscolored intact skin or blood-filledblister due to damage of underlying softtissue from pressure and/or shear.Further description: The area may bepreceded by tissue that is painful, firm,mushy, boggy, warmer or cooler ascompared to adjacent tissue. Deeptissue injury may be difficult to detect inindividuals with dark skin tones.Evolution may include a thin blister overa dark wound bed. The wound mayfurther evolve and become covered bythin eschar.17

Treatment ofpressure ulcersPressure ulcers treatment goals:1. Underlying pathology of the pressure ulcer must be treated, ifpossible. Pressure must be relieved or removed by appropriatemeasures to prevent further injury.2. Nutrition is important for healing of pressure ulcer:· Provide sufficient calories· Provide adequate protein for positive nitrogen balance· Provide and encourage adequate daily fluid intake for hydration· Provide adequate vitamins and minerals3. Wound care must be optimized:· If there is black or yellow necrotic tissue in the wound, considerdebridement to remove the dead tissue· If there is a high bacterial load (bioburden) in the wound, considerantimicrobial dressings· Cleanse the pressure ulcer and periwound area at each dressingchange· Use appropriate moist wound healing dressings· Dry wound - hydrate it· Wet wound - absorb it· Shallow wound - cover it· Deep wound - fill it / cover itDisclaimer:These are only general guidelines. There may be specific pressure ulcer treatment protocols used at your healthcare facility, which must be followed.18

Treatment ofpressure ulcersSHALLOWShallow Wound / Light DrainageShallow Wound / Heavy DrainageHydrocolloidLIGHTDRAINAGEFoam DressingDeep Wound / Light DrainageDeep Wound / Heavy DrainageHEAVYDRAINAGEWoun’Dres(Hydrogel)cover withcover withSeaSorb(Alginate)(Foam Dressing)Triad(Hydrophilic Paste)(Foam hallow Wound / Light DrainageShallow Wound / Heavy DrainageDeep Wound / Light DrainageDeep Wound / Heavy DrainageHEAVYDRAINAGE19

Wound infectionMost types of wounds contain bacteria. Even if the wound is healingnormally, a limited amount of bacteria will be present. Bacteriapresent in a chronic wound such as a pressure ulcer is referred to ascontaminated or colonized. But if the bacteria count rises, the woundmay become critically colonized or infected. Bacterial overload in awound can stall or delay healing and can lead to a serious infection.Antibiotic treatment and/or antimicrobial dressings may be required.Pressure ulcers that are critically colonized or infected may showsubtle signs of infection such as:4· Delayed healing· Change in odor· Increased serous exudate· Absent or friable granulation tissue· New or increased painSacrococcygeal pressure ulcerNPUAP copyright & used with permission20

Wound infectionIf a pressure ulcer is at-risk of infection or has become infected, anantimicrobial silver foam dressing may be helpful. Alternatively, asilver alginate dressing in combination with a foam dressing may beused.Autolytic DebridementAdditional clinical symptoms may arise if the infection spreads to thehealthy tissue surrounding the wound. Depending on the type ofPurilon (Hydrogel)bacteria, the wound exudate may become more pus-like, and theORCOVER WITHperiwound skin may be tender, red and painful. The patient may alsohave a fever. If the infection spreads beyond the wound, antibiotics(Foam Dressing)7should be used at the discretionofaphysician.Triad (Hydrophilic Paste)Addressing Bacterial BioburdenORPhoto courtesy of Stoia ConsultantsBiatain Ag(Silver Foam)COVER WITHSeaSorb Ag(Silver Alginate)(Foam Dressing)21

Wound debridementThe presence of necrotic or devitalized tissue in a wound promotesthe growth of bacteria and prevents wounds from healing.Debridement is the removal of nonviable tissue from a wound and isa naturally occurring part of the wound repair process.7It is important to select a debridement method(s) most appropriateto the person’s condition.····Surgical – removal of non-viable tissue by instrumentsMechanical – removal of non-viable tissue by physical forcesEnzymatic - removal of non-viable tissue by proteolytic substancesAutolytic – removal of non-viable tissue by phagocytic cells &proteolytic enzymesWhat to debride?· Slough – moist yellow, tan and/or gray non-viable tissue· Eschar – black, dry leathery non-viable tissueAutolytic DebridementPurilon(Hydrogel)ORCOVER WITHNPUAP.org Copyright 2011 Gordian Medical,Inc. dba American Medical Technologies.(Foam Dressing)Triad(Hydrophilic Paste)Addressing Bacterial Bioburden22ORCOVER WITH

Wound debridementAutolytic debridement is a highly selective, yet natural process, whereendogenous proteolytic enzymes break down devitalized tissue.*Triad Hydrophilic Wound Dressing(Zinc oxide-based paste)Case StudyDay 1Day 12Day 21All wound photos: M Boyle, 2007. Clinical case series: Using a hydrophilic wound dressingfor autolytic debridement. Coloplast.* Enoch S & Harding K (2003). Wound Bed Preparation: Wound Debridement. Wounds,15(7): 149-164.23

Dressing selectionWound dressings are a central component of pressure ulcer care.Dressing selection should be based on the type of tissue in thewound bed, the depth of the wound, the amount of wound exudateand the condition of the periwound skin. Suitable wound dressingsfor pressure ulcers are moist wound healing dressings with goodabsorption and exudate management properties.Dressings for deep pressure ulcersFill deep, draining wounds with dressing materials, e.g. alginate filler.Document the number of dressings that are used to fill large woundsto ensure all dressings are removed at the next dressing change.Dressings for infected pressure ulcersAssess pressure ulcers carefully for signs of infection and delay inwound closure. An antimicrobial moist wound healing dressing, e.g.a silver foam (Biatain Ag), or a silver alginate dressing (SeaSorb Soft Ag) in combination with an adhesive secondary dressing(Biatain Silicone) may help prevent or resolve wound infection.24

Dressing selectionPressure ulcers on the sacral area of patients who are incontinent areat higher risk for infection and further skin breakdown. To preventcontamination and protect the wound from urine and/or stool it isimportant to keep the wound and periwound area clean and use aprotective semi-occlu

education on pressure ulcer prevention and treatment, Coloplast has published this quick-guide. This guide is intended for educational and informational purposes only. It contains key recommendations for the prevention and treatment of pressure ulcers, and will be helpful to health care professionals who are

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