Pressure Ulcer Treatments and Prevention

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PRESSURE ULCER PREVENTION AND TREATMENTS

A pressure ulcer is an injury caused by unrelieved pressure that damages the skin and underlying tissue.

 

Intrinsic risk factors: limited mobility (eg, pain, fracture, neurological disorders, confinement to bed or chair), poor nutrition, comorbidities (eg, diabetes, depression, CHF, COPD, ESRD, Immunodeficiency), aging skin.

 

Extrinsic risk factors: pressure from hard surface, friction from inability to move in bed, shear from involuntary muscle movements, moisture (wound drainage, bowel or bladder incontinence, excessive sweating).

 

To estimate the level of risk for pressure ulcers, and to predict which patients are most likely to develop them, refer to the Braden Scale form. Risk Assessment should be done on admission and 48hrs later. Patients with a Braden score of 18 or below are at risk. Regular skin assessments for early signs of pressure injury are also essential.

CLASSIFICATION OF PRESSURE ULCERS
STAGE 1 An observable pressure related change in intact
skin compared to adjacent areas with regard
to temperature, tissue consistency, and/or sen-
sation. On lightly-pigmented skin, the area
appears as a defined area of persistent redness,
whereas on darker skin the area may appear
red, blue, or purple; in addition to skin discolor-
ation, edema, induration, or hardness may
also be indicators.
STAGE 2 Partial thickness skin loss involving epidermis,
dermis, or both, for example, abrasion, blister,
or shallow crater.
STAGE 3 Full thickness skin loss with damage to, or necrosis
of, subcutaneous tissue that may extend
down to, but not through, the underlying fascia.
Clinically presents as a deep crater.
STAGE 4 Full thickness skin loss with extensive destruc-
tion, tissue necrosis, or damage to muscle,
bone, or supporting structures such as tendons.
TREATMENT INTERVENTION

• Assess patients for skin changes. Nursing home patients should be assessed every 48hrs for the first week, then weekly for one month, then quarterly or more often if changes occur and/or if patient's status deteriorates.

 

• Focus assessment on location, stage and size of ulcer, presence of tracts or undermining, appearance of ulcer bed (granulation tissue, yellow slough, eschar, drainage, presence of rolled wound edges), odor, and peri-wound condition.

 

• Color photos taken on initial assessment reevaluation may be useful in monitoring changes in the wound.

 

• Remove necrotic tissue with sharp, mechanical, autolytic, or enzymatic debridement. Autolytic and enzymatic methods do not generally harm healthy tissue, but they may be slow. Sharp debridement is the most expedient method but it requires properly-trained personnel.

 

• Cleanse with normal saline or commercially prepared wound cleanser at each dressing change. Use adequate irrigation pressure (4–15psi) to cleanse without traumatizing. Avoid the use of antiseptics.

 

• Keep wound area moist. Apply dressings that maintain a moist wound environment (eg, hydrogels, hydrocolloids, saline-moistened gauze, transparent films).

 

• Keep peri-wound area (intact skin) dry.

 

• Rule out osteomyelitis if ulcer does not progress toward healing. Treat infection if present.

 

• Adjuvant therapies (eg, hyperbaric oxygenation, negative pressure, electrical stimulation) may be considered for unresponsive wounds in the absence of osteomyelitis.

 

• Do not swab cultures to diagnose wound infection. Consider topical antibiotic therapy (eg, Iodosorb, silver sulfadiazine, triple antibiotic, silver-impregnated dressings) for clean pressure ulcers that do not heal or that produce purulent exudate after 2–4wks of care.

 

• Protect from further injury to the ulcer or additional ulcer formation.

PREVENTATIVE INTERVENTIONS

• Assess patients for skin changes. Nursing home patients should be assessed every 48hrs for the first week, then weekly for one month, then quarterly or more often if changes occur and/or if patient's status deteriorates.

 

• Reposition patients who cannot reposition themselves at least every 2hrs.

 

• Encourage patients sitting in chairs who can reposition themselves to shift their weight every 15min.

 

• Avoid positioning patient directly on trochanter. May use a 30-degree instead of a 90 degree side-to-side turn.

 

• Keep the head of the bed at or below a 30 degree angle.

 

• Place a pressure-reducing surface on the bed or chair.

 

• Use site-specific support surfaces on extremities and bony prominences and keep bony areas from directly contacting each other; do not use donut-type devices.

 

• Keep skin dry and well-lubricated.

 

• Minimize skin injury due to friction and shearing. Use lifting devices when repositioning or lifting patients; do not drag skin across linens.

 

• Institute a nutritional support plan for those who may be nutritionally compromised. Ensure proper dentition and/or properly-fitting dentures.

 

• Begin rehabilitation if there is a possibility of improving mobility or activity status; encourage ambulation and range of motion exercises.

REFERENCES

Adapted from: Folkedahl BA, Frantz T. Prevention of pressure ulcers. Iowa City IA. Univ of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core, 2002 May 21. Brief summary at National Guideline Clearinghouse (www.guideline.gov).

 

Adapted from: Folkedahl BA, Frantz R. Treatment of pressure ulcers. Iowa City IA. Univ of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core, 2002 Aug. 30. Brief summary at National Guideline Clearinghouse (www.guideline.gov)

(Rev. 10/2014)

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