1. Steven Tam

2. Objectives  Understand the definitions and staging system for Pressure Ulcers  Review the epidemiology  Review risk factors for pressure ulcer development  Review and understand prevention and treatment of pressure ulcers

3. Case

4. The Case of “Just a Hygiene Problem”  Patient: 78 year old woman lives with her son (primary caregiver) history of diabetes difficulty walking (spinal stenosis?), wheelchair bound chronic edema brought in to the ER for altered mental status found to have a UTI 4

5. The Case of “Just a Hygiene Problem”  Skin not checked until the patient transferred to the ward floor  The RN notifies the Attending regarding the skin  The Attending says “it’s normal and just a hygiene problem” to nurse, in front of all other staff  Nurse calls APS 5

6. Is this normal? 6

7. PRESSURE ULCER: DEFINITION  Skin lesion caused by unrelieved pressure resulting in damage to soft tissue 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  Normal wound healing: Homeostasis, inflammatory, proliferative and maturation Aging can affect the wound healing process/phases

8. Pressure Ulcers 8

9. Pressure Sores September 2013National Institute on the Prosecution of Elder Abuse9

10. STAGING OF PRESSURE ULCERS (1 of 5) StageDefinition 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

11. STAGING OF PRESSURE ULCERS (2 of 5) StageDefinition Comments Stage IIntact 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 IIPartial-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

12. STAGING OF PRESSURE ULCERS (3 of 5) StageDefinition Comments Stage IIIFull-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

13. STAGING OF PRESSURE ULCERS (4 of 5) StageDefinition Comments Stage IVFull-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

14. STAGING OF PRESSURE ULCERS (5 of 5) StageDefinition Comments UnstageableFull-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

15. Epidemiology: Pressure Ulcers  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

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

17. PREVALENCE OF PRESSURE ULCERS VARIES BY STAGE

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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/

24. Prevention and Treatment

25. PREVENTION An evidence-based approach to preventing pressure ulcers focuses on: ○ Skin care ○ Nutrition ○ Mechanical loading ○ Mobility ○ Support surfaces

26. 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

27. 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

28. 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

29. 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)

30. 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

31. 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

32. STATIC SUPPORT SURFACES Foam Standard mattress Static flotation, air or water Support areaYesNoYes Low moisture retention No Reduced heat accumulation No Shear reductionNo Yes Pressure reduction YesNoYes Cost per dayLow

33. DYNAMIC SUPPORT SURFACES Air- fluidized Low air lossAlternating air Support areaYes Low moisture retention Yes No Reduced heat accumulation Yes No Shear reductionYes? Pressure reduction Yes Cost per dayHigh Moderate

34. 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

35. MANAGEMENT: ULCER ASSESSMENT Evaluate and document:  Location  Area  Stage  Depth  Drainage Necrosis Granulation Cellulitis Nonhealing wound

36. 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)

37.  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 PRESSURE ULCER SCALE FOR HEALING (PUSH)

38. 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

39. 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

40. MANAGEMENT: METHODS OF DEBRIDEMENT TypeMethodsComments MechanicalWet-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 EnzymaticTopical agent to dissolve dead tissue Use if no infection; may damage skin AutolyticAllows dead tissue to self-digest Use if other methods not tolerated and no infection; effect delayed BiosurgeryLarvae to digest dead tissue Quick, effective, good option when surgical debridement not an option

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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.

49. CASE 1 (2 of 3) Which of the following is the most effective management for this finding? A.Hyperbaric therapy B.Electromagnetic therapy C.Surgical debridement D.Turning patient every 2 hours

50. CASE 1 (3 of 3) Which of the following is the most effective management for this finding? A.Hyperbaric therapy B.Electromagnetic therapy C.Surgical debridement D.Turning patient every 2 hours

51. 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.

52. 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.

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

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

55. 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.

56. CASE 3 (2 of 3) Which of the following is the most appropriate treatment for this wound? A.Alginate dressing B.Hydrocolloid dressing C.Transparent film D.Wet-to-dry dressing

57. CASE 3 (3 of 3) Which of the following is the most appropriate treatment for this wound? A.Alginate dressing B.Hydrocolloid dressing C.Transparent film D.Wet-to-dry dressing

59. GRS8 Slides Editor: Annette Medina-Walpole, MD, AGSF GRS8 Chapter Author: Courtney H. Lyder, ND GRS8 Question Writer:R. Morgan Bain, MD Medical Writers: Beverly A. Caley Faith Reidenbach Managing Editor: Andrea N. Sherman, MS Copyright © 2013 American Geriatrics Society