AMDA Clinical Practice Guideline CPG for Pressure Ulcers

1
AMDA Clinical Practice Guideline(CPG) for
Pressure Ulcers

• For Medical Directors and Attending Physicians

2
What is a Pressure Ulcer?

• Any skin lesion usually over a bony prominence
  caused by unrelieved pressure resulting in
  damage to underlying tissue

3
Pressure Ulcers May Not be Preventable

• Aggressive measures can reduce but not eliminate
  the incidence of pressure ulcers
• Can develop despite best efforts of clinical team
  in high risk patients
• Every effort should be made to prevent pressure
  ulcers
• A systematic approach to recognize and manage
  pressure ulcers is needed

4
Factors Affecting Pressure Ulcer Development

• Pressure
• Shearing
• Friction
• Moisture

5
AMDA Pressure Ulcer CPG Steps

• Recognition
• Assessment/Root Cause Analysis
• Treatment
• Monitoring

6
Pressure Ulcers CPGRecognition

• Document any history of pressure ulcers in the
  medical record
• Thoroughly examine all skin surfaces on admission
• Identify all primary risk factors

7
Pressure Ulcers CPG Recognition

• Distinguish types of ulcers
• Vascular insufficiency/ischemia (venous stasis
  and arterial ischemic ulcers)
• Neuropathic
• Pressure

8
Pressure Ulcers CPG Recognition

• Primary risk factors for development of pressure
  ulcers are
• Impaired/decreased mobility
• Co-morbid conditions, e.g., diabetes mellitus
• Urinary or fecal incontinence
• Undernutrition, malnutrition, hydration
  deficits
• Impaired diffuse or localized blood flow
• Drugs such as steroids that may affect wound
  healing
• History of a healed pressure ulcer
• Resident refusal of some aspects of care
  treatment
• Intrinsic risks due to aging

9
Pressure Ulcers CPG Recognition

• Major Risk Factors for Developing Pressure Ulcers
• Alterations in sensation or response to comfort
• Degenerative neurological disease
• Cerebrovascular disease
• Central nervous system (CNS) injury
• Depression

10
Pressure Ulcers CPG Recognition

• Major Risk Factors for Developing Pressure Ulcers
• Causes of impaired/decreased mobility
• Neurologic disease/ injury
• Fractures
• Pain
• Restraints

11
Pressure Ulcers CPG Recognition Comorbid
Conditions That May Affect Ulcer Healing

• ?Malnutrition and dehydration
• ?Diabetes mellitus
• ?End-stage renal disease
• ?Thyroid disease
• ?Congestive heart failure
• ?Peripheral Vascular Disease

• ?Vasculitis/other collagen vascular disorders
• ?Immune deficiency states
• ?Malignancies
• ?COPD
• ?Depression and psychosis
• ?Drugs that affect healing
• ?Contractures at major joints

12
Pressure Ulcers CPG Assessment

• Pressure Ulcer Classifications
• Stage 1 Observable, pressure-related alteration
  of intact skin, including changes in skin
  temperature, tissue consistency, sensation,
  and/or defined area of persistent redness in
  light skin (red, blue or purple hues in dark
  skin)
• Stage 2 Partial thickness skin loss involving
  epidermis, dermis, or both. The ulcer is
  superficial and presents clinically as an
  abrasion, blister, or shallow crater

13
Pressure Ulcers CPG Assessment

• Pressure Ulcer Classifications continued
• Stage 3 Full thickness skin loss involving
  damage to, or necrosis of, subcutaneous tissue
  that may extend down to, but not through, fascia.
  The ulcer presents clinically as a deep crater
  with or without undermining of adjacent tissue
• Stage 4 Full thickness skin loss with extensive
  destruction, tissue necrosis or damage to muscle,
  bone, or supporting structures (e.g., tendon,
  joint capsule). Undermining and sinus tracts
  also may be associated

14
Pressure Ulcers CPG Assessment

• Ethical Issues To Consider
• Review Advance Directives
• Identify choices that limit the scope, intensity,
  duration and selection of various wound-related
  or adjunctive treatments

15
Pressure Ulcers CPG Assessment

• An effective assessment includes
• Define and interpret factors affecting treatment
  and wound healing such as physical, functional
  and psychosocial factors
• Define prognosis identify realistic goals
• Identify management priorities

16
Pressure Ulcers CPG Assessment

• Certain clinical findings may have priority
• Address systemic and life-threatening issues
• Stage 3 and 4 ulcers
• Significant pain
• Fluid and electrolyte abnormalities
• Nutritional deficits
• Need for surgical intervention to remove necrotic
  tissue
• Soft-tissue infection

17
Factors That Affect Wound Healing
Soft Tissue Infection
Pressure
SystemicIllness

• Wound healing is a complex multifactorial
  process

Oxygen
Osteomyelitis
Perfusion
Wound Environment
Systemic Healing Ability
Nutrition
Compliance
Edema
18
The Catabolic Response to a wound(Activation of
the Stress Response)
ENERGY PRODUCTION Mainly from glucose and amino
acids
A marked increase in energy demands and lean body
mass loss initiated by the stress response
Amino Acids
LEAN MASS Erosion (catabolism) of muscle
protein Visceral protein for glucose production
Net protein loss
Photos courtesy of R.H. Demling, MD.
19
The Nonhealing Chronic WoundFailure to Heal by
12 Weeks
The Nonhealing Wound
The Healing Wound
Wound contraction
Filling
Neutrophils
Densecollagenscar
O2
Catabolism
Catabolism
Anabolism
Anabolism
Energy
Protein Synthesis
Energy
Protein Synthesis
EnergyStore
Protein Store
EnergyStore
Protein Store
Macronutrients
Macronutrients
Courtesy of R.H. Demling, MD.
20
Pressure Ulcers CPG Treatment

• Wound prevention plan
• Wound treatment plan

21
Pressure Ulcers CPG Treatment

• Preventive measures
• ?Maintain personal hygiene
• ?Assure adequate nutrition
• ?Manage urinary/fecal incontinence
• ?Reposition and have patient shift weight
• ?Avoid messaging reddened areas
• ?Prevent contractures

• ?Position to alleviate pressure over bony
  prominences
• ?Use positioning devices/foam
• ?Maintain lowest head elevation
• ?Use lifting devices

22
Pressure Ulcers CPG Treatment

• Preventive Measures
• Important Points on Positioning and Support
  Surfaces
• Use a pressure-reducing mattress
• Avoid placing patient on trochanters or directly
  on wound
• Mattress options foam, air loss, water, gel,
  alternating air or viscoelastic
• Pressure relieving devices (e.g. air-fluidized
  mattress) where indicated

23
Pressure Ulcers CPG Treatment

• Preventive Measures
• Assuring adequate Nutrition and Hydration
• Watch for anorexia in patients with a sudden
  change in intake
• Undernourished patients caloric/protein/hydratio
  n targets
• 30-35 calories/kg/day
• 1-1.5 g/kg/day protein
• 30 ml/kg/day fluid
• Except for a daily multivitamin, other vitamin
  and mineral supplements are not needed unless
  deficiencies are confirmed

24
Pressure Ulcers CPG Treatment

• Preventive Measures A Step Wise Approach to
  Nutritional Intervention in Patients with Wounds
• Level 1 Approximately within first week after
  wound onset
• Level 2 Following completion of Level 1
  assessment
• Level 3 Approximately within 2 weeks of
  implementing Level 2
• Source AMDA Pressure Ulcer Therapy Companion
  Clinical Practice Guideline

25
Pressure Ulcers CPG Treatment

• Wound Care
• Principles of wound dressings
• Protect wound bed from further trauma,
  contamination or drying
• Promote removal of necrotic tissue and exudate
• Provide a moist healing environment supportive of
  regeneration and growth of granulation tissue.
• Wound characteristics change as the wound
  evolves. Tailor dressings primarily to wound
  characteristics, not wound stage

26
Pressure Ulcers CPG Treatment

• Wound Care Teams Possible Roles
• Help guide care by staying abreast of
  developments in the field
• Evaluate new products for formulary
• Provide consultation for difficult wounds
• Help select appropriate support surfaces for
  complex patients
• Train new staff
• Provide continuing education for existing staff
• Perform wound care

27
Pressure Ulcers CPG Treatment

• Wound Care Intact Skin
• Stage 1 Pressure Ulcers may herald a more
  extensive wound
• Protect involved area from further injury from
  pressure or shearing forces
• No dressing required
• Monitor frequently for changes

28
Pressure Ulcers CPG Treatment

• Wound Care Clean Wound Base
• Stage 2 or healing Stage 3 or Stage 4 wound
• Dressing should keep ulcer bed continually moist
  but the surrounding skin dry
• Choose dressing based on situation
• Fill wound dead space with loosely packed
  dressing material

29
Pressure Ulcers CPG Treatment

• Wound Care Eschar or Wound Base with Adherent
  Necrotic Tissue
• Additional treatments are indicated in wounds
  covered by eschar or with surface necrosis of
  subcutaneous tissue (without undermining adjacent
  tissue)
• Types of debridement used to remove eschar and
  surface necrosis
• Sharp surgical debridement
• Mechanical
• Enzymatic agents
• Autolytic
• Sterile biological (maggot)
• Dont use topical antibiotics routinely

30
Pressure Ulcers CPG Treatment

• Wound Care Extensive Subcutaneous Tissue Damage
• Stage 4 (some Stage 3) pressure ulcers are
  characterized by full thickness skin loss with
  extensive tissue necrosis, undermining and sinus
  tracts
• Treatment may require extensive surgical
  debridement
• All devitalized tissue removed
• Undermined areas should be explored and unroofed

31
Pressure Ulcers CPG Treatment

• Wound Care Categories of Products Used in Wound
  Care
• Hydrocolloids
• Alginates
• Foams
• Wound Fillers
• Composite Dressings

32
Pressure Ulcers CPG Treatment

• Wound Care Ongoing Management
• 1. Cleanse at each dressing change
• 2. Debride eschar, as needed
• 3. Evaluate/treat for infection
• 4. Employ facility infection control

33
Pressure Ulcers CPG Treatment

• Wound Care Ongoing Management (continued)
• 5. Re-evaluate co-existing medical conditions
• 6. Prescribe pain control measures
• 7. Address psychosocial issues, depression, and
  possible isolation

34
Pressure Ulcers CPG Treatment

• Wound Care Alternatives to Non-Responders
• For clean wounds not responding to appropriate
  treatment consider
• Topical antibiotic ointments/solutions for 2 week
  trial
• Progress to a support surface that offers further
  protection
• Consider a course of electrotherapy
• Consider transfer to another site for surgical
  debridement/repair, mgt. of systemic
  complications, comfort/pain mgt., and specialized
  diagnostic studies

35
Pressure Ulcers CPG Monitoring

• Regular weekly evaluations to assess healing
  (based on established Assessment Guides) to
  monitor success of the treatment regimen
• Follow-up diagnostic testing and consultation

36
Pressure Ulcers CPG Monitoring

• Document patient response to treatment
• Monitor and adjust treatment as indicated
• Recognize and manage complications

37
Pressure Ulcers CPG Monitoring

• Decide Whether To Change Treatment As Wound Heals
  
• Dressing types
• Debridement options
• Nutritional program
• Support surface options

38
Pressure Ulcers and Quality Improvement

• Goals of system to prevent and manage pressure
  ulcer
• Wound improvement/healing
• Prevent additional skin breakdown
• Prevent decline in overall condition
• Pain reduction

39
Pressure Ulcers and Quality Improvement

• Tips for risk management related to pressure
  ulcers
• Clear and consistent documentation in the chart
• Clearly defined roles and responsibilities
• Effective communication between shifts and
  disciplines
• Communication with families
• Document unavoidable factors that prevent healing
  or lead to worsening of pressure sores
• Policies and QA measures to ensure quality care

40
Summary

• Pressure ulcers continue to challenge nursing
  facilities
• Some ulcers are unavoidable, many develop prior
  in hospitals
• There is a need to maintain processes and systems
  to address prevention, recognition, and treatment
  that maximize the patients comfort, dignity and
  quality of life