Professional Documents
Culture Documents
1
Pressure Ulcer Assessment and
Management Objectives
By the end of the course participants will be able to:
Classify pressure ulcers by stage and differentiate ulcers of
non-pressure etiology.
Discuss current treatment practices and interventions for
pressure ulcer management.
Review key documentation areas for the medical record
management of pressure ulcers.
2
Overview of the Layers of the Skin
The skin is comprised of three major components:
Epidermis
Dermis
Subcutaneous tissue
3
What is a Pressure Ulcer?
Localized areas of tissue necrosis which develop when soft tissue
is compressed between a bony prominence and an external
surface for a prolonged period of time.
Unlike other ulcerations, which have a disease process associated
with their development or decline, pressure ulcers have
heightened requirements around: risk assessment; proactive
and therapeutic care giver interventions; assessment of
response to interventions and medical record management.
Most pressure ulcers occur over bony prominences, where
combined with friction and shearing forces result in skin
breakdown.
4
Most common sites in bed-
bound elderly
Supine:
23% sacrococcygeal
8% heels
1% occiput; spine
Sitting:
24% ischium
3% elbows
Lateral:
15% trochanter
7% malleolus
6% knee
3% heels
5
Classification of Wounds
The staging of pressure ulcers, as defined by national guidelines
(NPUAP, CMS, AHCPR), allow for common understandings
for healthcare professionals. The staging of a pressure ulcer
reflects the amount of tissue damage. Outside of the MDS,
only pressure ulcers are staged – stage I – IV, UTD and DTI.
6
Pressure Ulcers
7
Stage I Pressure Ulcer
The ulcer appears as a defined area of persistent red, blue, or
purple hues in lightly pigmented skin.
In darker skin tones, the ulcer may appear with discoloration,
warmth, edema, induration or hardness.
8
Stage I Pressure Ulcer Treatment Options
Stage I on Trunk of the Body –
Manage incontinence, keeping area clean and dry.
Use moisture barrier as needed.
Off load area were pressure ulcer is – pressure reducing surfaces
Stage I on Heels –
Ensure that heel(s) are floated at all times with frequent monitoring.
9
Stage II Pressure Ulcer
Partial thickness skin loss involving epidermis, dermis, or both.
The ulcer is superficial and presents clinically as an abrasion,
blister, or shallow crater.
10
Stage II Pressure Ulcer Treatment Options
Dry Wound Bed –
Cleanse with normal saline, apply small amount of hydrogel and cover
with dd every day.
Off load area were pressure ulcer is – pressure reducing or relieving
surfaces.
Minimal Drainage –
Cleanse with normal saline, apply hydrocolloid dressing every three days
and prn soiling or dislodging. Monitor placement every day.
Off load area were pressure ulcer is – pressure reducing or relieving
surfaces.
11
Stage III Pressure Ulcer
Full thickness skin loss involving damage to or necrosis of
subcutaneous tissue that may extend down to, but not
through, underlying fascia.
12
Stage III Pressure Ulcer Treatment Options
Minimal Drainage and Clean Wound Bed –
Cleanse with normal saline, apply small amount of hydrogel and cover
with dd every day.
Off load area were pressure ulcer is – pressure relieving surfaces.
Presence of Slough –
Cleanse with normal saline, apply Accuzyme and cover with dd every
day.
Use Foam dressing instead of dd for heavy drainage.
Off load area were pressure ulcer is – pressure relieving surfaces.
Heavy Drainage and Clean–
Cleanse with normal saline, apply foam dressing every two days and prn
soiling or dislodging. Monitor placement every day.
Off load area were pressure ulcer is – pressure relieving surfaces –
preferable a low air loss mattress replacement. 13
Stage IV Pressure Ulcer
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 present.
14
Stage IV Pressure Ulcer Treatment Options
Minimal Drainage and Clean Wound Bed –
Cleanse with normal saline, apply small amount of hydrogel and cover
with dd every day.
Off load area were pressure ulcer is – pressure relieving surfaces –.
Presence of Slough –
Cleanse with normal saline, apply Accuzyme and cover with dd every
day.
Use Foam dressing instead of dd for heavy drainage.
Off load area were pressure ulcer is – pressure relieving surfaces –
preferable a low air loss mattress replacement.
Heavy Drainage and Clean–
Cleanse with normal saline, apply foam dressing every two days and prn
soiling or dislodging. Monitor placement every day.
Off load area were pressure ulcer is – pressure relieving surfaces – 15
preferable a low air loss mattress replacement.
UTD (Unable to Determine Stage)
Pressure Ulcer
When a pressure ulcer wound bed is covered with non-viable
tissue such as “slough” or “eschar” the pressure ulcer can not
be staged as visualization of the amount of tissue damage /
involvement is impossible.
16
UTD Stage Pressure Ulcer
Treatment Options
Presence of Slough –
Cleanse with normal saline, apply Accuzyme and cover with dd every
day.
Use Foam dressing instead of dd for heavy drainage.
Off load area were pressure ulcer is – pressure relieving surfaces –
preferable a low air loss mattress replacement.
Heavy Drainage and Clean–
Cleanse with normal saline, apply foam dressing every two days and
prn soiling or dislodging. Monitor placement every day.
Off load area were pressure ulcer is – pressure relieving surfaces –
preferable a low air loss mattress replacement.
Note – intact eschar on the lower extremities (i.e. heels) should not be
actively debrided but should have pressure managed – floating of the
heels 17
Deep Tissue Injury
These wounds present as intact skin with dark purple shading
almost to black area usually within a reddened area of
skin. This represents a pressure injury of an unknown depth
so this wound cannot be staged – also known as “Purple
Pressure Injury” or “Pre-Eruptive Full-Thickness Pressure
Ulcer.”
18
Causative Factors for the Development
of Pressure Ulcers
Immobility or limited mobility
Incontinence
Shearing and friction injuries
Advanced age
Malnutrition or under-nutrition
Significant obesity or thinness
History of pressure ulcers
Dehydration
Contractures
Use of orthotic devises or restraints
Issues of resident compliance
19
Immobility and Pressure Ulcers – CMS
Statements
Some statements around tissue load management from CMS:
20
Immobility and Pressure Ulcers – CMS
Statements
“Depending on the individualized assessment, more frequent
repositioning may be warranted for individuals who are at
higher risk for pressure ulcer development or who show
evidence (e.g., Stage I pressure ulcers) that repositioning at
two hour intervals is inadequate.”
21
Interventions for the Management
of Immobility
Individualized re-positioning schedules with thorough
communication of needs and expectations
Use of appropriate pressure relieving or reducing support
surfaces
Float heels
Keep sheets free from wrinkles
Avoid raising the head of bed more than 30 degrees
As appropriate, perform active or passive range of motion
exercises to relieve pressure and promote circulation
Adjust or pad appliances, casts, or splints as needed to ensure
a proper fit and to prevent pressure and impaired circulation
22
Interventions for the Management
of Incontinence
Implement as appropriate a bowel and bladder retraining
program
Ensure healthful hydration through adequate daily fluid
intake
Assess environmental issues – accessibility, manual dexterity
(how easily can the resident manipulate their clothing)
Regular reminders to void with prompt response to toilet
Fiber rich diets
Promote regular exercise
Maintain effective hygiene care, cleaning the perineal area
frequently with use of a moisture barrier
23
Shearing and Friction
Shear -
The gravitational pull of the body downward while the
skin stays stationary on the surface of bed or chair.
This gravitational pull creates a change in the angle of
capillaries.
Friction –
Result from forces that tend to cause two opposing
surfaces to slide and displace against each other.
24
Shearing Injury
25
Interventions for the Prevention of
Shear and Friction Injuries
Assuring that individuals are being repositioned and that
nursing staff understand:
Use of proper transferring and positioning equipment
26
Interventions for the Management
of Malnutrition “Under-Nutrition”
RD assessment and recommendations – should be at least
every month if a pressure ulcer is present
Monitoring intake and output with communication of any
changes in patterns
Provide needed dental care
Follow prescribed diets – protein supplementation, thickened
liquids
Offer liquids as appropriate at each care giving activity
Encourage intake
Maintain accurate medical record information for MD and
RD – weights and I/O’s
27
Overview of General Treatment
Interventions for Pressure Ulcers
General considerations for the treatment of pressure ulcers:
Manage the moisture.
Remove non-viable tissue.*
Enzymatic
Sharp debridement
Mechanical debridement
Tissue load management – never placing resident directly on
an existing wound – use appropriate support surfaces.
Protect the peri-wound tissue.
29
Arterial Ulcerations
Venous Stasis Ulcerations
Neuropathic Ulcerations
30
Arterial Ulcerations
Cause – Inadequate circulation to the legs
Contributing Factors:
31
Arterial Ulcerations Clinical Presentation
Small, deep, punched out lesions
Well demarcated, smooth edges
Often contain necrotic tissue and / or pale wound beds
Ulcers frequently appear on tips of toes or fingers and over
phalangeal heads
Ulcers may also appear around heels and ankles, sides and
plantar surface of the foot
32
Treatment Interventions for
Arterial Ulcers
The only treatment for arterial ulcerations is surgical intervention,
re-establishing circulation. Many of our LTC residents are
not surgical candidates. In this case make sure to have the
MD document the fact that the benefits of vascular surgical
intervention are out weighed by the risk of the procedure. It
is also important to have the resident (if appropriate) and the
family members understand this as well.
33
Venous Stasis Ulcerations
Affect 3.5% of the population
Have approximately 70% recurrence rate
Anatomy and Physiology of Venous Stasis Ulcers
Incompetent, malfunctioning valves:
Contribute to backflow
Result in increased pressure within veins
Allow leakage of serum and blood cells into tissue
Create edema
Presents with hemosiderin staining
Ulcerations
34
Venous Stasis Ulcerations
Clinical Presentation
Superficial
Irregular in shape
Usually not painful / sensitive
Usually occur on medial aspect of leg
Brawny edema, deep, ruddy red tissue
Legs appear hard and wooden-like
Often heavily draining ulcers
35
Treatment Interventions for
Venous Stasis Ulcers
The treatment for venous stasis ulcers is surgical repair of the
malfunctioning valves. As with arterial ulcerations, many of
our LTC residents are not surgical candidates. In this case
make sure to have the MD document the fact that the benefits
of vascular surgical intervention are out weighed by the risk
of the procedure. It is also important to have the resident (if
appropriate) and the family members understand this as well.
37
Medical Record
Documentation for
Wound Care
38
Medical Record Risk Management
for Pressure Ulcers
Unlike other ulcerations, which have a disease process
associated with their development or decline, pressure ulcers
have heightened requirements around: risk assessment;
proactive and therapeutic care giver interventions; assessment
of response to interventions and medical record management
Risk Assessment
MD notification / participation in plan of care
Actual and Potential care plans
IDT interventions and notes
Treatment records with response to interventions
39
Assessment Parameters
Wounds need to have the following assessed:
Etiology – if not pressure then the MD should document as well
Stage if pressure
Size – length by width by depth and tunneling if present
Wound bed tissue characteristics
Periwound tissue characteristics
Signs and symptoms of infection
Response to current interventions
40
Miscellaneous Discussion
Points on Wound Healing
“Healed” vs. “Re-surfaced”
Tensile strength at end of proliferation phase and the
remodeling phase
Regulatory risk of re-occurrence
Assessment of scar tissue
41
Closing Questions and
Comments
42
Quality Improvement Resources
Lumetra
www.Lumetra.com
Advancing Excellence Campaign
http://www.nhqualitycampaign.org/
MedQIC
www.medqic.org
Setting Targets – Achieving Results
(STAR)
A password-protected Web site created for
nursing homes
View current performance trends for six Quality
Measures (QMs):
High-risk pressure ulcers
Post acute pressure ulcers
Chronic care pain
Post acute pain
Depression
Physical restraints
Set annual performance targets.
Set your QM targets at www.nhqi-star.org.
To Get Your CEU Credit