F. PRINCIPLES OF TREATMENT BASED ON ETIOLOGY (TREAT THE CAUSE)

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1 F. PRINCIPLES OF TREATMENT BASED ON ETIOLOGY (TREAT THE CAUSE) F.3. PRESSURE ULCER (PU) 3.1. PU Background and Extent of Etiology (from the SWCCAC Wound Management Program March 2011) A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers: poor nutritional status, impaired mobility, low level of activity, impaired sensory perception, advanced age, low arteriole pressure, poor oxygenation, unresolved moisture on skin, friction and shear, number and severity of comorbidities. You can never back stage an ulcer e.g. once a stage IV, always a stage IV. The Wound Ostomy Continence Nurses Society in the USA has developed the following definitions about avoidable and unavoidable pressure ulcers (go to WOCN Library tab then go to Position Papers): AVOIDABLE PRSSURE ULCERS Occur when the resident develops a pressure ulcer and the facility did NOT do one or more of the following: evaluate the resident s clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; or monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. UNAVOIDABLE PRESSURE ULCERS The resident developed a pressure ulcer even though the facility had: evaluated the resident s clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. Skin Changes At Life s End (SCALE) Kennedy Terminal Ulcer (KTU) is a type of pressure ulcer that some individuals develop as they are dying. It can be shaped like a pear, butterfly, or horseshoe, usually on the coccyx or sacrum but can occur in other areas. The ulcers can appear as red, yellow or black, occur suddenly, and usually indicate that death is imminent (Sibbald, Krasner et al 2008). SWRWC Toolkit: F.3 Pressure Ulcer Background and Introduction_June_21_2011 1

2 Instructions for use 3.2. Algorithm This algorithm has been provided by Systagenix for use in the SWRWC Toolkit. It is based on the Wound Bed Preparation algorithm, but incorporates many of the RNAO Best Practice Guidelines NPUAP Staging System for Pressure Ulcers (Updated 2007) Suspected Deep Stage I Stage II Stage III Stage IV Unstageable Tissue Injury Reproduction of the National Pressure Ulcer Advisory Panel (NPUAP) materials in this document does not imply endorsement by the NPUAP of any products, organizations, companies or statements made by any organization or company. The following definitions are available online at Suspected Deep Tissue Injury Evolution of DTI may include a thin blister over a dark wound bed become covered by thin eschar May heal or Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. Blood blisters included in DTI & represent a deeper level of injury than a serum filled blister yet the true depth of tissue damage is not known. Stage I Intact skin with non blanchable 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. May be painful, firm, soft, warmer or cooler as compared to adjacent tissue. May indicate "at risk" persons (a heralding sign of risk) Stage II Partial thickness loss of dermis Shallow open ulcer with a red pink wound bed, without slough, or Intact or open/ruptured serum filled blister. shiny or dry shallow ulcer without slough or bruising. SWRWC Toolkit: F.3 Pressure Ulcer Background and Introduction_June_21_2011 2

3 * This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. *Bruising indicates suspected deep tissue injury Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed or directly palpable Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Depth varies by anatomical location: Shallow on bridge of the nose, ear, occiput and malleolus Extremely deep in areas of significant adiposity can develop stage III pressure ulcers. Stage IV Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a stage IV pressure ulcer varies by anatomical location: The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. 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. NB*** 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. SWRWC Toolkit: F.3 Pressure Ulcer Background and Introduction_June_21_2011 3

4 3.4 Self Care Teaching Tool and 3.5 Client/Patient Teaching and Learning Resources My Pressure Ulcer The SWCCAC has worked in collaboration with their contracted service providers to identify and create resources that will aid in the delivery of Best Practices for this client population. The CCAC version of the self care teaching tool and client handout are presented here. Once this version has been piloted in the SW in the summer of 2011, the Clinical Evaluation subcommittee working with the CCAC and other partners will look at making these into regional tools that can be adapted to all sectors. 3.6 Selection of Surfaces for Pressure Redistribution Ideally, a Physiotherapist or Occupational Therapist would complete a mat assessment and evaluate pressure with a pressure mapping unit. Please see Section 3.2 Interdisciplinary Pressure Ulcer Contributing Factors Assessment Tool. Based on pressure points/areas they will often connect with vendors to find a product fit that best meets the individual client needs. In Acute or Long Term Care settings where there is a contract with a specific pressure redistribution surface company, the companies generally provide laminated triage cards for each nursing station, but the appropriateness of the product for the individual client/patient/resident should be assessed by an OT or PT with this knowledge. The RNAO s Assessment & Management of Stage I to IV Pressure Ulcers has two suggested resources: Appendix F: Support Surface Considerations and Appendix G: Positioning and Support Surfaces A Checklist, available at: 3.7 Evidence Based Clinical Interventions Determine client s goals New Pressure Ulcer Wound Initiative to be launched March 21 May 21, 2011 Healing Service Plan Wound Healing Client/caregiver teaching of wound care, prevention of recurrence Decrease dressing changes Maintenance Service Plan Maintain wound environment. Teach client/caregiver wound management. Goals may now be pain, exudate and odour control. Wound Assessment: Use a validated and reliable wound assessment tool and Stage Pressure ulcers per NPUAP Staging system (see 3.3) Other: Dietitian if nutritional deficiencies are identified. Optimize nutritional intake and general health status. SWRWC Toolkit: F.3 Pressure Ulcer Background and Introduction_June_21_2011 4

5 Braden Scale for Pressure Sore Risk and interventions based on identified risk e.g. continence issues= Nurse Continence Advisor referral OT assessment: Pressure redistribution surfaces are critical to prevention and healing. PT referral for : Mobilization/ mobility issues Adjunctive Therapy assessment if client has Spinal Cord Injury (SCI) (after June 1, 2011 in SWCCAC) Adjunctive Therapy assessment if wound has not healed at 3 months(after June 1, 2011 in SWCCAC) Healing Service Plan Principles of wound bed preparation: debridement, bacterial balance, exudate control, protect periwound skin. *NB Note that the RNAO BPGs for Assessment and Management of Stage I to IV Pressure Ulcers recommends that dressings should be selected based on the principles of moist wound healing For dry healing wounds: Hydrogel (to rehydrate) covered with Hydrocolloid, or occlusive/ semi occlusive exudate absorptive dressings For exudating healing wounds: Hydrofiber or alginate covered by exudate absorptive dressings Topical Negative Pressure therapy (VAC) may be appropriate following surgical intervention for Stage III or IV healable pressure ulcers (not eligible in SWCCAC for chronic wounds) For maintenance wounds Betadine soaked gauze and absorbent cover dressing Common Dressing Supplies* for infection/bacterial burden management See Section 3.3 Cover with exudate absorptive dressings. If unsure of the type of infection, choose a non occlusive dressing. Maintenance/ Palliative Service Plan Avoid higher cost advanced wound treatment and focus on exudate and odour management, quality of life issues. 3.8 Resources Keast D.H., Parslow, N. Houghton, PE., Norton,L. and Fraser, C. (2006) Best Practice Recommendations for the Prevention and Treatment of Pressure Ulcers: Update Wound Care Canada 4(1):R See PDF. Used with Permission. The RNAO Clinical Best Practice Guidelines for the Risk Assessment and Prevention of Pressure Ulcers and the Assessment and Management of Stage I IV Pressure Ulcers are available for free download at: and SWRWC Toolkit: F.3 Pressure Ulcer Background and Introduction_June_21_2011 5

6 References: Sibbald RG, Krasner DL, Lutz JB, et al. The SCALE Expert Panel: Skin Changes At Life s End. Preliminary Consensus Document. September SWRWC Toolkit: F.3 Pressure Ulcer Background and Introduction_June_21_2011 6

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