Pressure Ulcers - LWW
Fighting back against pressure ulcers Copyright 2009 Wolters Kluwer Health Lippincott Williams & Wilkins
Up to 40% of critical care patients have these wounds. Find out how one facility took steps to reduce that rate. By Rosemary Jones Kates, RN, APN-BC, CRNP, CWOCN, MSN, and Amy Callahan, RN, APN-BC, CRNP, CNE, MSN BRIAN EVANS / PHOTO RESEARCHERS, INC. P Pressure ulcers are a complex healthcare problem that affect quality of life and often contribute to sepsis and death. Preventing and treating pressure ulcers in the United States is estimated to be a 1.3 million industry; the Centers for Medicare and Medicaid Services (CMS) reports that the average cost of treating a pressure ulcer is about 43,180.1,2 Although there are wide variations, the national incidence of pressure ulcers in acute care has been reported to be 7% to 9%; prevalence (the total number of pressure ulcers at a specific point in time) averages 14% to 17%.1 In CCUs, the incidence and prevalence vary from 8% to 40%, according to data collected by the National Pressure Ulcer Advisory Panel from 1990 to 2000.3 Critically ill patients are at increased risk for developing pressure ulcers, which greatly increases their morbidity and mortality. Factors that increase pressure ulcer risk for critical care patients, compared with medical-surgical patients, include multisystem organ failure, multiple comorbidities, hemodynamic instability, vasoactive drugs, sensory impairment, mechanical ventilation, immo- www.nursing2009criticalcare.com bility, and incontinence.4 Other risk factors for critically ill patients include malnutrition, multiple surgical interventions, emergency admission, transfer from outside facilities, and prolonged hospitalization.5 Some research suggests that patients with diabetes, sepsis, stroke, cardiovascular disease, or hypotension are at higher risk because of the resultant microcirculatory dysfunction.6 For more on pressure ulcer development, see Getting into pressure ulcers. Various studies have looked at the costs associated with increased length of stay, debridement, wound care supplies, and nursing time, but these costs don’t begin to measure the enormity of the problem. Indirect costs such as the pain and suffering of the patient and family, increased potential for infection, sepsis, and death can’t be measured. Can pressure ulcers be prevented? Pressure ulcers are considered preventable, despite a long-standing debate as to whether some are unavoidable. Even with the best prevention strategies in place, some experts believe that pressure ulcers may be unavoidable in some critically ill patients in mul- tisystem organ failure. The skin, like other bodily systems, can fail.2 Healthcare facilities must develop standards of care and implement measures to reduce the incidence of healthcareassociated pressure ulcers. The Agency for Healthcare Policy and Research (now the Agency for Healthcare Research and Quality) released clinical practice guidelines for prevention in 1992. The CMS has identified pressure ulcers as one of eight diagnoses that are reasonably preventable, and no longer reimburses facilities if patients acquire pressure ulcers in acute care. The Institute for Healthcare Improvement (IHI) has named pressure ulcer prevention as one of five goals in its 5 Million Lives Campaign. The American Nurses Association has identified maintenance of skin integrity and decreasing pressure ulcer incidence as a nursing quality indicator. Key elements of pressure ulcer prevention programs include identifying at-risk patients; implementing prevention protocols; educating patients, families, and healthcare providers; and developing strategies to enhance communication among healthcare providers. Nurses continue to be leaders in developing standards September l Nursing2009Critical Care l Copyright 2009 Wolters Kluwer Health Lippincott Williams & Wilkins 35
Fighting back against pressure ulcers for preventing pressure ulcers and managing them when they occur. A successful prevention program requires commitment across the organization, involving all disciplines. Patients with darkly pigmented skin are at higher risk for pressure ulcer development and may be more likely to die from pressure ulcers.7 Because these patients don’t have persistent redness or nonblanchable erythema, Stage I pressure ulcers may be difficult to detect. Look for skin discoloration or other subtle changes such as changes in skin temperature (warmer or cooler), firmness, bogginess, or pain, compared with other areas. The National Pressure Ulcer Advisory Panel has revised the definition of Stage I pressure ulcers to reflect these differences.8 Although nurses often are the first healthcare providers to recognize subtle changes in a patient’s skin, pressure ulcers aren’t just a nursing problem. Because the etiology of pressure ulcers is multifaceted, prevention needs to include the entire medical team (nurses, physicians, nutritionist, physical therapists, and social service workers) as well as the patient and family members. Assessing risk Start with pressure ulcer risk assessment and develop an individualized plan of care to reduce your patient’s risk of developing a pressure ulcer. The Braden Scale and the Norton Scale are both validated and reliable assessment tools in predicting patients at risk (see Braden Scale for predicting pressure ulcer risk). Perform a risk assessment, as well as a skin assessment to detect existing pressure ulcers or changes in skin integrity.2 All patients should be assessed on admission and reassessed at least every 24 hours, and with any change in their clinical status. Getting into pressure ulcers Pressure ulcers are defined as a localized injury to the skin and underlying structures as a result of pressure, sometimes in combination with shear and or friction. They usually occur over a bony prominence. A number of contributing factors are also associated with pressure ulcers; the significance of these factors has yet to be elucidated. Factors contributing to pressure ulcer development include: Immobility. Patients diagnosed with recent fractures, stroke, sensory impairment secondary to sedation, or an underlying abnormality causing them to be immobile for any length of time are at greatest risk. Duration and intensity of pressure. Low pressure for a long time can be as damaging as high pressure for a short time. Tissue tolerance (the ability of the tissues to tolerate the pressure). For example, muscle is more sensitive to pressure damage than skin.3 Collagen production. Collagen is important in maintaining skin integrity, and production can be decreased by age, malnutrition, and use of steroids. Tissue perfusion, which can be affected by serum protein, anemia, hypotension, extracorporeal circulation, diabetes, and use of vasoactive drugs.3 Extrinsic factors such as friction, shear, and moisture and irritants (such as from incontinence), which are disruptive to the epidermis. 36 l Nursing2009Critical Care l Volume 4, Number 5 The Braden Scale, the most widely used assessment tool in the United States, assesses patient risk in six subsets. Mobility, activity, and sensory perception evaluate the effects of pressure intensity and duration; moisture, nutrition, and friction and shear evaluate the tissue’s ability to tolerate pressure.3,9 Each subscale contains a numerical range of scores. A total score of 23 is possible and indicates no risk. Older patients and those with darkly pigmented skin are at risk for pressure ulcer development if they score 18 or less; other adults are at risk if they score 16 or less, and a score of 9 or less indicates very high risk. Evaluate the patient’s subset scores and intervene in the areas with the lowest scores (see Protocols by risk level from the Braden Scale). For instance if the patient is identified as at risk in nutrition, your plan of care should include monitoring calories, increasing protein, administering dietary supplements, and consulting a nutritionist. For a patient with a low score in activity, implement a turning schedule, place the patient on a pressure-reducing support surface, and protect his heels by elevating them off the bed. Although highly reliable, the Braden Scale may not capture all of the patient’s risk factors, especially in a critically ill patient. Be sure to take a complete patient history and consider other risk factors (such as diabetes, hypotension, age, and medications) in your care planning. Assessing skin regularly The next step is to perform a comprehensive skin assessment on patient admission and at periodic intervals. The IHI www.nursing2009criticalcare.com Copyright 2009 Wolters Kluwer Health Lippincott Williams & Wilkins
suggests that skin inspections should be done at least every 24 hours in acute care. Critically ill patients will need more frequent assessments. Under new CMS regulations, the admission skin assessment must be completed not only by the nurse in acute care but also by the physician, so the facility can be reimbursed appropriately if the patient has an existing Stage III or Stage IV pressure ulcer. Perform a comprehensive head-to-toe skin assessment with particular emphasis on pressure points and areas at greatest risk usually over pressure points such as the heels, sacrum, occiput, malleolus, and ischium. Assess the patient’s skin temperature, turgor, moisture, and integrity.2 One facility’s experience In an effort to decrease the incidence of pressure ulcers in our medical ICU (MICU), we formed an interdisciplinary team consisting of the wound, ostomy, and continence nurse (WOCN) specialist; the clinical nurse specialist; the MICU staff nurses; physicians; nutritionists; physical therapists; and occupational therapists. Our program included an education plan, a designated day for wound care rounds, and collaboration between all disciplines involved in the prevention and management of pressure ulcers in critically ill patients. We developed a tool to ensure that the Braden Scale was completed according to protocol and proper interventions were initiated. In addition to the regular daily rounding, we do formal rounding as a team on “Wound Care Wednesday.” The team consists of the clinical specialist, the www.nursing2009criticalcare.com Because patients and families are critical to pressure ulcer prevention efforts, they’re invited to participate in wound care rounds if they’re able. WOCN specialist, and nursing staff. All patients in the unit are assessed for potential or actual skin breakdown, and the team collaborates and develops a plan for prevention and treatment. This time provides the WOCN specialist an opportunity to talk to educate the staff at the bedside. For all patients with skin breakdown, the WOCN specialist is consulted to ensure that the patient is receiving appropriate treatment. On a daily basis, the physician team rounds on the MICU and discusses any patient skin integrity issues with the nursing staff and nutritionist. Physician involvement in skin assessment is part of our initiative; all patients are assessed by the physicians for alterations in skin integrity on admission and in collaboration with the nursing staff when a need is identified. The WOCN specialist is available to the team and to support education for the nurses and the medical team. Because patients and families are critical to these efforts, they’re invited to participate in wound care rounds if they’re able, and are always kept abreast of any skin integrity issues and prevention measures. Educating clinical staff was a key component to the success of this program. The clinical nurse specialist, WOCN specialist, nutritionist, and physical therapist provided education, including demonstrations, on identifying at-risk patients, skin assessment, staging pressure ulcers, wound interventions, nutritional support, and documentation. In 2008, a patient lift system was included in the education program to reinforce proper techniques for lifting patients during transfer and positioning them to decrease friction and shear. The nutritionist reviews enteral feeding solutions and supplements used in critical care patients, including highprotein supplements that help maintain skin integrity and facilitate skin healing. At MICU admission, all patients undergo a complete skin assessment and Braden Scale risk assessment. These assessments are repeated every 12 hours. Patients identified as at risk for pressure ulcers receive additional preventive interventions and pressure ulcer treatments as appropriate and according to the hospital’s skin and pressure ulcer protocol. Most patients in the MICU are immobile and require regular turning, proper positioning, and pressure-relieving devices. We consult physical and occupational therapists to mobilize patients as soon as possible and help with positioning issues September l Nursing2009Critical Care l Copyright 2009 Wolters Kluwer Health Lippincott Williams & Wilkins 37
Fighting back against pressure ulcers Braden Scale for predicting pressure ulcer risk Sensory perception—ability to respond meaningfully to pressurerelated discomfort 1. Completely limited—unresponsive (doesn’t moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation OR limited ability to feel pain over most of body 2. Very limited— responds only to painful stimuli. Can’t communicate discomfort except by moaning or restlessness OR has some sensory impairment that limits the ability to feel pain or discomfort over half of body 3. Slightly limited— responds to verbal commands, but can’t always communicate discomfort or the need to be turned OR has some sensory impairment that limits ability to feel pain or discomfort in 1 or 2 extremities 4. No impairment— responds to verbal commands. Has no sensory deficit that would limit ability to feel or voice pain or discomfort Moisture—degree to which skin is exposed to moisture 1. Constantly moist—skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. 2. Very moist—skin is often, but not always, moist. Linen must be changed at least once a shift. 3. Occasionally moist—skin is occasionally moist, requiring an extra linen change about once a day 4. Rarely moist— skin is usually dry, linen only requires changing at routine intervals Activity—degree of physical activity 1. Bedfast—confined to bed 2. Chairfast—ability to walk severely limited or nonexistent. Can’t bear own weight and/or must be assisted into chair or wheelchair. 3. Walks occasionally—walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair. 4. Walks frequently– walks outside room at least twice a day and inside room at least once every two hours during waking hours Mobility—ability to change and control body position 1. Completely immobile—doesn’t make even slight changes in body or extremity position without assistance 2. Very limited— makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently 3. Slightly limited— makes frequent though slight changes in body or extremity position independently 4. No limitation— makes major and frequent changes in position without assistance Nutrition—usual food intake pattern 1. Very poor—never eats a complete meal. Rarely eats more than one-third of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Doesn’t take a liquid 2. Probably inadequate—rarely eats a complete meal and generally eats only about half of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally 3. Adequate—eats over half of most meals. Eats a total of 4 servings of protein (meat or dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when 4. Excellent—eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. (continued) 38 l Nursing2009Critical Care l Volume 4, Number 5 www.nursing2009criticalcare.com Copyright 2009 Wolters Kluwer Health Lippincott Williams & Wilkins
Braden Scale for predicting pressure ulcer risk Friction and shear (continued) dietary supplement OR is N.P.O. and/or maintained on clear liquids or I.V.s for more than 5 days will take a dietary supplement OR receives less than optimum amount of liquid diet or tube feeding offered Doesn’t require OR supplementation. is on a tube feeding or total parenteral nutrition regimen that probably meets most of nutritional needs 1. Problem—requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction. 2. Potential problem— moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. 3. No apparent problem—moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair. Used with permission of Barbara Braden and Nancy Bergstrom. on patients with special needs. For example, if a patient is hemodynamically unstable and can’t tolerate complete turns, the physical therapist may devise a plan that uses wedges and small weight shifts to relieve pressure. The MICU nutritionist rounds with the interdisciplinary team daily. Nutrition assessments and nutrition goals are evaluated by the nutritionist. Maintaining skin integrity in incontinent patients is always a challenge. The hospital has a standard protocol for protecting skin integrity in incontinent patients, but needed something more advanced to prevent and treat pressure ulcers in patients with diarrhea. After careful consideration and a review of the literature to identify best www.nursing2009criticalcare.com practices, we recently initiated use of a fecal management system to divert stool from critically ill patients’ skin. The system reduces skin contamination and helps to maintain a clean and dry environment that reduces the risk of skin breakdown and supports healing. In developing guidelines for the use of this product, we recognized that other measures should be used before resorting to a rectal tube. First, nurses needed to work with the medical team and nutritionist to identify and treat the underlying cause of diarrhea. Measures such as skin cleaning, skin barriers, and a fecal incontinence pouch should be tried first. The fecal management system, which requires a written order and a digital rectal exam by the physician to assess sphincter con- trol, should be used only after all other measures fail. The process to implement the use of this device was multidisciplinary. Nursing drove the initiative to improve and maintain skin integrity. As part of our Professional Practice Council, nurses from the MICU and the medical coronary care unit were involved in product selection, trial, and evaluation. The clinical nurse specialists from both units and the WOCN specialist provided support in protocol development and education, which included nursing and medical staff. Gastroenterologists reviewed the protocols. We perform pressure ulcer prevalence studies monthly to measure the success of our efforts. A complete skin assessment is done on all patients in the unit on the day September l Nursing2009Critical Care l Copyright 2009 Wolters Kluwer Health Lippincott Williams & Wilkins 39
Fighting back against pressure ulcers Protocols by risk level from the Braden Scale At risk (15-18)* Frequent turning Maximal remobilization Protect heels Manage moisture, nutrition, and friction and shear Pressure-reduction support surface if bed- or chairbound Manage moisture Use commercial moisture barrier Use absorbent pads or diapers that wick and hold moisture Address cause if possible Offer bedpan or urinal and glass of water in conjunction with turning schedules Moderate risk (13-14)* Turning schedule Use foam wedges for 30-degree lateral positioning Pressure-reduction support surface Maximal remobilization Protect heels Manage moisture, nutrition, and friction and shear Manage nutrition Increase protein intake Increase calorie intake to spare proteins Supplement with multivitamin (should have vitamins A, C, and E) Act quickly to alleviate deficits Consult nutritionist High risk (10-12) Increase frequency of turning Supplement with small shifts Use foam wedges for 30-degree lateral positioning Pressure-reduction support surface Maximal remobilization Protect heels Manage moisture, nutrition, and friction and shear Manage friction and shear Elevate head of bed no more than 30 degrees Use trapeze when indicated Use lift sheet to move patient Protect elbows and heels if being exposed to friction Very high risk (9 or below) All of the above plus Use pressure-relieving surface if the patient has intractable pain, severe pain exacerbated by turning, or additional risk factors Other general care issues No massage of reddened bony prominences No doughnut-type devices Maintain good hydration Avoid drying the skin * If other major risk factors are present, advance to the next level of risk. Major risk factors are: advanced age, fever, poor dietary intake of protein, diastolic BP below 60, or hemodynamic instability. Used with permission of Barbara Braden. of the study. Patients with pressure ulcers are identified and medical records are reviewed to determine if the pressure ulcers were present on admission or developed during the hospitalization. The MICU averages a 7% incidence for hospital-acquired pressure ulcers and continues to strive to improve. Meeting the challenges to prevent pressure ulcers is ongoing and includes reevaluating protocols and continuing to educate staff members, patients, and families. Constant communication among team members is key. 40 REFERENCES 1. Kring D. Reliability and validity of the Braden Scale for predicting pressure ulcer risk. J Wound Ostomy Continence Nurs. 2007;34(4):399–406. 2. Armstrong DG, Ayello E, Capitulo K, et al. New opportunities to improve pressure ulcer prevention and treatment: implications of the CMS inpatient hospital care present on admission indicators/hospitalacquired conditions policy: a consensus paper from the International Expert Wound Care Advisory Panel. Adv Skin Wound Care. 2008;21(10):469–478. 3. Baranoski S, Ayello E. Wound Care Essentials: Practice Principles. Lippincott Williams & Wilkins; 2008. 4. Elliott R, McKinley S, Fox V. Quality improvement program to reduce the prevalence of pressure ulcer in an intensive care unit. Am J Crit Care. 2008:17(4):328–334. 5. Padula C, Osborne E, Williams J. Preven- l Nursing2009Critical Care l Volume 4, Number 5 tion and early detection of pressure ulcers in hospitalized patients. J Wound Ostomy Continence Nurs. 2008;35(1):65–75. 6. Lyder C. Pressure ulcer prevention and management. JAMA. 2003;289(2):223–226. 7. Lyder C. Closing the skin assessment disparity gap between patients with light and darkly pigmented skin. J Wound Ostomy Continence Nurs. 2009;36(3):285. 8. National Pressure Ulcer Advisory Panel. http://www.npuap.org. 9. Magnan M, Maklebust J. The nursing process and pressure ulcer prevention: making the connection. Adv Skin Wound Care. 2009;22(2):83–92. Rosemary Jones Kates is a wound, ostomy, and continence nurse at Jefferson University Physicians in Cherry Hill, N.J. Amy Callahan is a critical care clinical nurse specialist in the medical intensive care unit at Jefferson University Hospital in Philadelphia, Pa. www.nursing2009criticalcare.com Copyright 2009 Wolters Kluwer Health Lippincott Williams & Wilkins
Fighting back against pressure ulcers 36 l Nursing2009CriticalCare l Volume 4, Number 5 www.nursing2009criticalcare.com for preventing pressure ulcers and managing them when they occur. A successful prevention program requires commitment
Aug 09, 2016 · Wound Incidence/Prevalence About 2% of the U.S. adult population has a chronic wound. Chronic wounds are considered: pressure ulcers/injuries lower extremity ulcers diabetic foot ulcers venous ulcers and arterial ulcers Prevalence is measured by the number of cases of pressure ulcers at a specific time. Incidence measures the number of new pressure ulcers without
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developed and provide specific treatment recommendations for stage 2 or higher pressure ulcers, including proper wound care (5). This Data Brief presents the most recent national estimates of pressure ulcer prevalence, resident characteristics associated with pressure ulcers, and the use of wound care services in U.S. nursing homes.
The goal of this guideline is to provide evidence based recommendations for the prevention and treatment of pressure ulcers that can be used by health professionals throughout the world. The purpose of the prevention recommendations is to guide evidence based care to prevent the development of pressure ulcers and the purpose of the treatment
11. Cox J. Predictors od Pressure Ulcers in Adult Critical Care Patients. Amer J Crit Care 2011;20(5):364-374. 12. Delmore B, Cox J, Rolnitzky L, Chu A, Stolfi A. Differentiating Pressure Ulcers from Acute Skin Failure in the Adult CriticalCa re Patie
The Adventure Tourism Development Index (ATDI) is a joint initiative of The George Washington University and The Adventure Travel Trade Association (ATTA). The ATDI offers a ranking of countries around the world based on principles of sustainable adventure tourism
