PRESSURE ULCERS & WOUND CARE Suggestions for Lecturer -1-hour lecture -Use GNRS slides alone or to supplement your own teaching materials. -Refer to GNRS for further content, including strength of evidence (SOE) levels. -Refer to Geriatrics At Your Fingertips for detailed information on ulcer evaluation, management, and dressings. -Supplement lecture with handouts, such as the Braden Scale and Norton Scale. -The GNRS Teaching Slides reflect care that can be provided to older adults in all settings. The words patient, resident, and older adult have been used interchangeably, as have the words provider, clinician, and primary care provider. Given the continually ongoing changes in health care today, some of the guidelines around reimbursement may have changed since publication. Topic

OBJECTIVES Know and understand: The morbidity and mortality associated with pressure ulcers for older adults The common risk factors for pressure ulcer development Techniques for preventing pressure ulcers The pressure ulcer staging system and treatment strategies for each stage

TOPICS COVERED Epidemiology Complications Risk Factors and Risk Assessment Prevention Ulcer Assessment and Staging Monitoring and Treatment

PRESSURE ULCER: DEFINITION Any lesion caused by unrelieved pressure that results in damage to underlying soft tissue when the tissue is compressed between a bony prominence and external surface over a prolonged period of time The time for pressure ulcer development is variable due to severity of illness and number of comorbid conditions

THE WOUND HEALING CASCADE The normal wound healing cascade comprises 4 phases: Homeostasis Inflammatory Proliferative Maturation Aging can affect the wound healing phases and thus delay or impede the healing process

PRESSURE ULCERS: A MAJOR ISSUE IN GERIATRIC MEDICINE Affect 1 million adults annually Higher risk in older people 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 Medicare and most states’ Medicaid programs do not pay for hospital-acquired stage III or IV pressure ulcers CMS = Centers for Medicare and Medicaid Services Two main factors are believed to play a major role in pressure ulcer formation: pressure and shear forces. It appears that the amount of pressure or shear force needed to create a pressure ulcer depends on the quality of tissue, the blood flow, and the amount of pressure applied. Hence, for patients with poor-quality tissue (ie, tissue with inadequate blood perfusion), it may take less sustained pressure over a shorter time to develop a pressure ulcer. Conversely, patients with good-quality tissue may be able to sustain more pressure over a longer time before an ulcer develops. Ulcers caused by shearing forces tend to develop deep in the fascia, whereas ulcers caused by friction tend to be quite superficial, starting in the epidermal and dermal layers.

STAGING OF PRESSURE ULCERS (1 of 5) Stage Definition Comments 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 than adjacent tissue Deep tissue injury can be difficult to detect in individuals with dark skin tones Evolution can include a thin blister over a dark wound bed The wound can further evolve and become covered by thin eschar Evolution can be rapid and expose additional layers of tissue, even with optimal treatment Staging according to the National Pressure Ulcer Advisory Panel

STAGING OF PRESSURE ULCERS (2 of 5) Stage Definition Comments 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 The area may be painful, firm, soft, and warmer or cooler than adjacent tissue Stage I can be difficult to detect in individuals with dark skin tones Stage II Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough Can also present as an intact or open/ruptured serum-filled blister Presents as a shiny or dry shallow ulcer without slough or bruising (the latter indicates suspected deep tissue injury) This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation

STAGING OF PRESSURE ULCERS (3 of 5) Stage Definition Comments Stage III Full-thickness tissue loss Subcutaneous fat can be visible but bone, tendon, or muscle are not exposed Slough may be present but does not obscure the depth of tissue loss Can include undermining and tunneling Depth varies by anatomic 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 (4 of 5) Stage Definition Comments Stage IV Full-thickness tissue loss with exposed bone, tendon, or muscle Slough or eschar can be present on some parts of wound bed Often include undermining and tunneling Depth varies by anatomic location The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and these ulcers can be shallow Stage IV ulcers can extend into muscle and/or supporting structures (eg, fascia, tendon or joint capsule), making osteomyelitis possible Exposed bone/tendon is visible or directly palpable

STAGING OF PRESSURE ULCERS (5 of 5) Stage Definition Comments 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 wound bed Until enough slough and/or eschar is removed to expose the base of the wound, 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

INCIDENCE OF PRESSURE ULCERS VARIES BY SETTING 0–17% 11% 7%–9%

PREVALENCE OF PRESSURE ULCERS VARIES BY STAGE

POSSIBLE COMPLICATIONS Sepsis (aerobic or anaerobic bacteremia) Localized infection, cellulitis, osteomyelitis Pain Depression Mortality rate = 60% in older people who develop a pressure ulcer within 1 year of hospital discharge

RISK FACTORS Intrinsic: physiologic factors or disease states that increase the risk for pressure ulcer development Age Nutritional status Decreased arteriolar blood pressure Extrinsic: external factors that damage skin Pressure, friction, shear Moisture, urinary, or fecal incontinence

FACTORS PREDICTIVE OF PRESSURE ULCER DEVELOPMENT Age 70+ Impaired mobility Current smoking Low BMI Confusion Urinary and fecal incontinence Malnutrition Restraints Many other disorders: malignancy, diabetes, stroke, pneumonia, CHF, fever, sepsis, hypotension, renal failure, dry skin, history of pressure ulcers, anemia, lymphopenia, hypoalbuminemia

RISK ASSESSMENT INSTRUMENTS Widely used tools for identifying older patients at risk of developing ulcers: Norton scale Sensitivity = 73%–92%, specificity = 61%–94% Braden scale Sensitivity = 83%–100%, specificity = 64%–77% Both are recommended by Agency for Healthcare Research and Quality

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

Provides method for assessing pressure ulcer risk by evaluating: BRADEN SCALE Provides method for assessing pressure ulcer risk by evaluating: Sensory perception: ability to respond to pressure- related discomfort Moisture: degree of exposure to moisture Activity: degree of physical activity Mobility: ability to change and control body position Nutrition: usual food intake http://www.bradenscale.com/

An evidence-based approach to preventing pressure ulcers focuses on: PREVENTION An evidence-based approach to preventing pressure ulcers focuses on: Skin care Nutrition Mechanical loading Mobility Support surfaces See Agency for Healthcare Research and Quality, 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. In 2009, the National Pressure Ulcer Advisory Panel (NPUAP) and the European Pressure Ulcer Advisory Panel (EPUAP) published clinical guidelines on the prevention and treatment of pressure ulcers. It should be noted that the vast majority of recommendations remain expert opinion.

PREVENTION: SKIN CARE (1 of 2) Daily systematic skin inspection and cleansing Especially bony prominences Use warm water and mild cleanser Reduce factors that promote dryness Avoid low humidity and exposure to cold Moisturize dry skin Avoid massaging over bony prominences

PREVENTION: SKIN CARE (2 of 2) Reduce moisture Incontinence Perspiration Drainage Minimize friction and shear Use proper repositioning, turning, transferring techniques Use lubricants, protective films, dressings, padding

PREVENTION: NUTRITION Maintaining optimal nutrition continues to be part of national pressure ulcer prevention guidelines However, the relationship between protein-calorie malnutrition and its relationship with pressure ulcer development is unclear Avoid over-supplementing patients who do not have protein, vitamin, or nutritional deficiency Review goals of care prior to considering enteral or parenteral nutrition The CMS guidelines on pressure ulcer care (F-Tag 314) for nursing homes suggest that a resident with a nutritional risk should have a minimum of 1.25 to 1.5 g/kg of protein per day.

PREVENTION: MECHANICAL LOADING Reposition at least every 2 h (may use pillows, foam wedges) Use lubricants and protective dressings/pads 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, as they may cause pressure ulcers Pay special attention to heels (account for 20% of all pressure ulcers)

PREVENTING HEEL ULCERS (1 of 2) 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 (eg, stroke patients) Single or extra-thick hydrocolloid dressing for those with pre-stage I reactive hyperemia

PREVENTING HEEL ULCERS (2 of 2) Have patients wear: Socks to prevent friction (remove at bedtime) Properly fitting sneakers or shoes when in wheelchair Place pillow under legs to keep heels off bed Turn patients every 2 hours, repositioning heels

PREVENTION: MOBILITY Increasing and maintaining mobility is one of the most effective ways to decrease pressure on bony prominences Bedbound patients benefit from active and passive range of motion exercises

PRESSURE-REDUCING SUPPORT SURFACES Use for all older people at risk of 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

STATIC SUPPORT SURFACES Foam Standard mattress Static flotation, air or water Support area Yes No Low moisture retention Reduced heat accumulation Shear reduction Pressure reduction Cost per day Low SOURCE: Adapted from Bergstrom N, Bennett MA, Carlson CE, et al. Treatment of Pressure Ulcers. Clinical Practice Guideline No. 15. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. December 1994:38. AHCPR Pub. No. 95-0652. For more detail, see Table 38.2 in GNRS4.

DYNAMIC SUPPORT SURFACES Air-fluidized Low air loss Alternating air Support area Yes Low moisture retention No Reduced heat accumulation Shear reduction ? Pressure reduction Cost per day High Moderate SOURCE: Adapted from Bergstrom N, Bennett MA, Carlson CE, et al. Treatment of Pressure Ulcers. Clinical Practice Guideline No. 15. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. December 1994:38. AHCPR Pub. No. 95-0652. For more detail, see Table 38.2 in GNRS4.

MANAGEMENT: GENERAL ASSESSMENT Identify and effectively manage issues that have placed patient at risk of pressure ulcers: Medical diseases Health problems (eg, urinary incontinence) Nutritional status Pain level Psychosocial health

MANAGEMENT: ULCER ASSESSMENT Evaluate and document: Location Area Stage Depth Drainage Necrosis Granulation Cellulitis Nonhealing wound For details about evaluating and documenting these factors, see Table 38.3 in GNRS4. 32

MANAGEMENT: MONITORING HEALING Document all observations over time Describe each ulcer to track progress of healing Do not use “reverse staging” For example, stage IV cannot become stage III 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 Use validated tools (eg, PUSH, see next slide)

PRESSURE ULCER SCALE FOR HEALING (PUSH) 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

MANAGEMENT: CONTROL OF INFECTIONS (1 of 2) Wound cleansing and dressing are the keys Increase 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 Avoid routine swab cultures

MANAGEMENT: CONTROL OF INFECTIONS (2 of 2) If still no healing, consider possible cellulitis or osteomyelitis Biopsy for culture of underlying tissue, bone May need systemic antibiotics

MANAGEMENT: METHODS OF DEBRIDEMENT Type Methods Comments Mechanical Wet-to-dry irrigation, hydrotherapy May remove both dead and live tissue; may be painful Surgical, sharp Scalpel, scissor to remove dead tissue; laser debridement Quick, effective; use for infection; pain management needed Enzymatic Topical agent to dissolve dead tissue Use if no infection; may damage skin Autolytic Allows dead tissue to self-digest Use if other methods not tolerated and no infection; effect delayed Biosurgery Larvae to digest dead tissue Quick, effective, good option when surgical debridement not an option

MANAGEMENT: DRESSINGS (1 of 3) Transparent film: stage I, protects from friction Contraindicated: draining, suspected infection or fungus Foam island: stages II, III Contraindicated: 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 See GNRS4 Table 38.6 for details.

MANAGEMENT: DRESSINGS (2 of 3) Alginate: stages III and 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

MANAGEMENT: DRESSINGS (3 of 3) Gauze packing: stages III, IV Contraindicated: deep wounds, especially those with tunneling, undermining Consider silicone-based dressings to decrease pain Silver dressings: malodorous wounds, exudative wounds, and those highly suspicious for critical bacterial load Contraindicated: systemic infection, cellulitis, fungus, interstitial nephritis, skin necrosis, concurrent use with proteolytic enzymes

MANAGEMENT: NUTRITION Ensure adequate diet; prevent malnutrition Weak evidence for nutritional support that achieves 30 to 35 calories/kg/day and 1.25 to 1.5 g of protein/kg/day Weak evidence for supplemental vitamins and minerals

MANAGEMENT: SURGICAL REPAIR May be used for stage III and IV ulcers Direct 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, hyperbaric oxygen Promising research continues: Recombinant platelet-derived growth factors Electrical stimulation Vegetative pressure wound therapy

SUMMARY Older adults are at high risk of developing 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

CASE 1 (1 of 3) A 92-year-old woman is examined because a nurse has identified a suspicious area of skin on the right buttock. The patient underwent open-reduction internal fixation repair of a fractured right hip a few days earlier and was transferred to the Acute Care for the Elderly (ACE) unit from the surgery service. On examination, there is a 4 cm × 4 cm area on the right lateral buttock. It has a blood-filled blister that remains intact with surrounding dark tissue.

CASE 1 (2 of 3) Which of the following is the most effective management for this finding? Hyperbaric therapy Electromagnetic therapy Surgical debridement Turning patient every 2 hours 46

CASE 1 (3 of 3) Which of the following is the most effective management for this finding? Hyperbaric therapy Electromagnetic therapy Surgical debridement Turning patient every 2 hours ANSWER: D The wound described in this case is a suspected deep-tissue injury ulcer. The main goal is to relieve pressure by turning the patient every 2 hours. A 2010 NPUAP consensus conference upheld the recommendation of turning patients every 2 hours as a guideline but not as a standard of care. Turning schedules may be lengthened depending on patient characteristics and pressure relief surfaces. Suspected deep-tissue injury was introduced in the 2007 update of the NPUAP pressure ulcer staging system. The revision came in response to the observation that patients could quickly progress from intact skin to severe stage III and stage IV ulcers in a manner different from that of simple stage I ulcers. The new category helps to differentiate typical stage I ulcers with nonblanching erythema and intact skin from pressure ulcers that have damage caused by other mechanisms, yet have intact skin. Suspected deep-tissue injury pressure ulcers can appear as either a localized area of intact skin that is purple or maroon, similar to a deep bruise, or as a blood-filled blister. Thus far, there are no specific treatment recommendations for suspected deep- tissue injury ulcers, and they are to be treated as any other stage I pressure ulcer. Hyperbaric therapy, electromagnetic therapy, and surgical debridement are indicated for other stages of pressure ulcers and types of wounds but are not recommended for suspected deep-tissue injury ulcers. 47

CASE 2 (1 of 4) A 72-year-old man who has metastatic colon cancer is admitted to a hospice inpatient facility because of complete bowel obstruction and failure to thrive. He has been unable to tolerate oral food or fluids for several days because of nausea and vomiting, and he has significant pain throughout the day. The hospice admitting nurse documents a large sacral pressure ulcer measuring 11 cm × 10 cm, with a depth of 4 cm. There is surrounding erythema, exposed muscle, undermining of the edges, and a tunneling tract that extends another 2 cm.

CASE 2 (2 of 4) Within the ulcer, there is necrotic material and a significant amount of exudate with a foul odor that permeates the room. The treatment plan includes placement of a specialized bed overlay, application of absorptive dressings, and medicine for pain control. Family members tell staff that the wound odor makes spending time in the patient’s room very difficult, and they ask if something can be done.

CASE 2 (3 of 4) Which of the following is the best next step to reduce odor from the pressure ulcer? Turn patient every 2 hours. Apply topical metronidazole gel. Place potpourri in the room. Perform surgical debridement. 50

CASE 2 (4 of 4) Which of the following is the best next step to reduce odor from the pressure ulcer? Turn patient every 2 hours. Apply topical metronidazole gel. Place potpourri in the room. Perform surgical debridement. ANSWER: B Severe pressure ulcers tend to have polymicrobial infection with both aerobic and anaerobic bacteria that can cause significant odor. NPUAP guidelines recommend use of topical metronidazole to control pressure ulcer odor associated with anaerobic bacteria and protozoal infections. A white paper published in 2010 by the NPUAP, developed in conjunction with its European counterpart EPUAP, addresses palliative care issues in patients with pressure ulcers. The goal of pressure ulcer treatment—to promote healing and closure of the wound—may not be possible in patients receiving palliative care. Thus, the focus of care is better directed to reducing or eliminating pain, odor, and infection; allowing for an environment that can promote ulcer closure; and supporting the patient’s self-image to help prevent social isolation. The guidelines offer many suggestions to help reduce odor, including frequent cleansing of the ulcer and periwound area, routine assessments for wound infection, use of antimicrobial agents, and use of external odor absorbers for the room. While turning patients every 2 hours is important for healing of pressure ulcers, patients receiving palliative care may be unable to turn frequently because of pain or personal or family preference. Additionally, frequent turning would not directly address the issue of odor in this case. Placing potpourri or other odor absorbers in the room is also recommended, but the absorbers do not directly reduce odor caused by bacteria, and they too can create an odor that overwhelms the room. Surgical debridement of pressure ulcers is sometimes indicated to remove necrotic material to help reduce growth of bacteria, and by extension odor, but debridement is often invasive and painful, and thus conflicts with the goals of palliative care. 51

CASE 3 (1 of 3) A 68-year-old woman is transferred to a medical ward after being treated in the intensive care unit for respiratory failure due to COPD. During an examination, the nurse notices an area of skin breakdown on the patient’s coccyx. It is 3 cm × 4 cm with a depth of 1 cm and has minimal slough. The wound edges are hyperemic, but there is no sign of undermining. Wound exudate is minimal, and there are no systemic signs of infection.

Hydrocolloid dressing Transparent film Wet-to-dry dressing CASE 3 (2 of 3) Which of the following is the most appropriate treatment for this wound? Alginate dressing Hydrocolloid dressing Transparent film Wet-to-dry dressing 53

Hydrocolloid dressing Transparent film Wet-to-dry dressing CASE 3 (3 of 3) Which of the following is the most appropriate treatment for this wound? Alginate dressing Hydrocolloid dressing Transparent film Wet-to-dry dressing ANSWER: B This wound has minimal slough, indicating that the ulcer penetrates into the subcutaneous fat tissue. Because no muscle, tendon, or bone is visible, it is a stage III pressure ulcer. The description of minimal exudates and the lack of systemic infection indicate that the wound is not infected. Hydrocolloid dressings are recommended for noninfected stage III ulcers. Alginate dressings are intended for wounds that have moderate to heavy exudates. Blood and exudates are absorbed to create a gel that protects wound surfaces. Because the wound in this case has minimal exudates, alginate dressings are not the best treatment option. A transparent film dressing is semipermeable, retains moisture, and is adhesive. It can provide autolytic debridement or cover other dressings for larger wounds as a secondary dressing. It is intended to reduce friction for stage I and II pressure ulcers. Transparent film dressing is contraindicated for wounds with exudates or suspected infection. Because the wound described in this case has an exudate, albeit minimal, transparent film is inappropriate as a sole agent for the wound. Wet-to-dry dressings are not recommended for treatment of pressure ulcers, because they may damage healthy, granulating tissue and cause pain with dressing changes. 54

and questions by R. Morgan Bain, MD GNRS4 Teaching Slides Editor: Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF GNRS4 Teaching Slides modified from GRS8 Teaching Slides based on chapter by Courtney H. Lyder, ND and questions by R. Morgan Bain, MD Managing Editor: Andrea N. Sherman, MS Copyright © 2014 American Geriatrics Society