CHAPTER SEVEN. Skin Integrity and Pressure Ulcers: Assessment and Management BACKGROUND ASSESSMENT

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1 Ch007-X0223.qxd 9/12/2006 6:16 PM Page 1 SECTION ONE GENERAL APPROACH TO A HOSPITALIZE PATIENT CHAPTER SEVEN Skin Integrity and Pressure Ulcers: Assessment and Management Jonathan M. Flacker, M BACKGROUN The skin is the first line of defense against the environmental threats of the outside world. Compromised integrity puts patients at risk for discomfort and infection. Anything that breaches the skin barrier, including lacerations, burns, dermatitis, skin tears, and pressure ulcers, can compromise its integrity. This chapter will focus on skin tears and pressure ulcers that are both commonly encountered and often avoidable in the hospital setting. Pressure ulcers are any lesion caused by unrelieved pressure resulting in damage of underlying tissue. Pressure ulcers are associated with four underlying causes: pressure, shear, friction, and moisture. Pressure, usually on a bony prominence, is the primary cause of such ulcers. Shear, or the interaction of gravity and friction on the skin, contributes to pressure ulcers by causing twisting or kinking of blood vessels. Friction damages the skin at the epidermal/dermal interface (the basement membrane). Moisture contributes to pressure ulcer development by weakening the cell wall of individual skin cells. Taken alone, or more commonly in combination, these four factors place patients at high risk for breakdown of skin integrity. ASSESSMENT Clinical Presentation Prevalence and Presenting Signs and Symptoms The prevalence of pressure ulcers is difficult to pinpoint in the acute-care setting due to the various methodologies used in published studies; the prevalence, however, seems to be % with an incidence of %. One recent large survey found overall hospital pressure ulcer prevalence was 14.8%, with a nosocomial pressure ulcer prevalence of 7.1%. Thus, about half of hospitalized patients with pressure ulcers develop them in the hospital. Staging of pressure ulcers is standardized using a I IV scale (Table 7-1) ranging from superficial redness being stage I to a stage IV ulcer extending into muscle, bone, or supporting structures (Fig. 7-1). Pressure ulcers have important characteristics that should be examined and documented (Box 7-1). Using the black, yellow, red system to describe ulcer bed color gives a sense of the viabil- ity of the exposed tissue. Red corresponds to the presence of muscle or granulation tissue in wound bed. Yellow indicates necrotic tissue or slough in wound bed and/or presence of subcutaneous tissue, fascia, or support structures like ligaments/ tendons. Black wounds have necrotic eschar within or obscuring the wound. The presence of dead space, such as undermining or tunneling must be assessed and managed to prevent complications such as premature wound closure and/or abscess formation. Ulcer margins also have implications for wound healing. When intact, this indicates that the skin surrounding the wound is attached to the edge of the ulcer bed, and epithelialization of the ulcer can occur more readily. Complete circumferential undermining means the ulcer margins are not attached. Skin tears, often a precursor to pressure ulcers, are classified separately from pressure ulcers. Their true prevelance is unknown. The Payne-Martin Classification system is commonly used to stage skin tears. Category I is a skin tear without tissue loss. Category II denotes a skin tear with partial tissue loss. Category III indicates a skin tear with complete tissue loss and absent epidermal flap. ifferential iagnosis Pressure ulcers most commonly occur over area of bony prominences. When they occur elsewhere on the body, an external source of frequent, constant pressure must be present. This external pressure source may be the patient s own limb, as in the case of contractures or orthopedic abnormalities. At other times, the external pressure may come from the patient s environment, such as broken or ill-fitting wheelchair parts, bed frames, or chairs. Tight or ill-fitting clothing, shoes, bra straps, and orthopedic splints may also be a source of external pressure. An ulcer appearing on a part of the body that does not have a source of frequent constant pressure is probably not a pressure ulcer, but rather has another etiology such as vascular insufficiency, infection, or local trauma. Note that so-called stage I ulcers are not yet ulcerated. Stage I ulcers may be more difficult to detect in patients with darker skin, but are often evidenced by a purple discoloration (especially under halogen light) and/or bogginess/induration of the skin. Stage I ulcers may thus be confused with simple bruising. Any new bruise over a bony prominence or an area of frequent pressure should be suspected to be a stage I pressure ulcer.

2 Ch007-X0223.qxd 9/12/2006 6:16 PM Page 2 2 Comprehensive Hospital Medicine: An Evidence Based and Systems Approach Stage 1 Malnutrition Stage 2 Table 7-1 Pressure Ulcer Staging Stage I Stage II Stage III Stage IV Unstageable Pressure Shear Bone Muscle Subcutaneous fat ermis Epidermis Support surface Bone Muscle Subcutaneous fat ermis Epidermis Support surface Malnutrition The pressure area does not penetrate the epidermis, but rather appears as a defined area of persistent redness in lightly pigmented skin, but may be red, blue, or purple in darker skin. Observable pressure related alteration of the intact skin may include one or more of: a. Skin temperature (warmth or coolness) b. Tissue consistency (firm or boggy feel) c. Abnormal sensation such as pain and/or, itching. The ulcer appears as a defined area of persistent redness. Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and may appear as an abrasion, blister, or shallow erosion. Full-thickness skin loss involving damage and/or necrosis of subcutaneous tissue that forms a crater down to, but not through, underlying fascia. Full-thickness skin loss that extends through underlying fascia to involve destruction, necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). A wound bed that is covered or obscured by eschar cannot be staged. Adapted from: NPUAP Position Statement on Pressure Ulcer Prevention, National Pressure Ulcer Advisory Panel, Shear Figure 7-1 Pressure Malnutrition Moisture Algorithm. Stage 4 Stage 3 Shear Pressure Moisture Necrotic tissue Bone Muscle Subcutaneous fat ermis Epidermis Support surface Bone Muscle Subcutaneous fat ermis Epidermis Support surface iagnosis Preferred Studies The diagnosis of a pressure ulcer is a clinical one. Laboratory studies are focused on a good nutritional assessment. Prealbumin is the most sensitive indicator of nutritional status in hospitalized patients. It has a 2-day half-life, whereas albumin has a 21-day half-life and can be affected by hydration status. When quantification of bacterial levels in the ulcer is desired, a correctly done swab, tissue biopsy, and needle aspiration each have similar accuracy, sensitivity, and specificity. 13 To properly swab culture a pressure ulcer, clean the wound thoroughly with normal saline, then debride down to the base of the wound. Roll the swab a full rotation on the deepest part of the wound with the most visible signs of infection. Eschar should never be cultured. With stage IV ulcers, the question of osteomyelitis often arises. Clinical examination is highly inaccurate for determining if osteomyeli-tis is present, and x-rays are typically unhelpful. Bone biopsy remains the gold standard for determining the presence of osteomyelitis. Jamshidi core needle bone biopsy has been shown to have reasonable test characteristics for osteomyelitis (sensitivity of 73%; specificity of 96%) and may be especially useful for guiding therapy prior to surgical closure of a pressure ulcer. CT scans exhibit poor sensitivity for osteomyelitis in patients with pressure sores, while technicium and gallium bone scans have poor specificity. Indium-labeled WBC scans have not been adequately studied in the setting of pressure ulcers. MRI seems to perform significantly better, but clear data on accuracy and costeffectiveness are not yet available. Prognosis uring Hospitalization Recent information on the implications of pressure ulcers for patient prognosis is lacking. One older study found that 67% of patients who develop a pressure ulcer during a hospitalization

3 Ch007-X0223.qxd 9/12/2006 6:16 PM Page 3 Box 7-1 Pressure Ulcer Evaluation Key Elements of Assessing the Physical State of the Pressure Ulcer: Size including depth Location Stage Necrotic tissue Slough Exudate Infection Granulation tissue Undermining Tunneling Abscess formation Visible subcutaneous tissue/fascia/ligaments/tendons/ bone Pain Odor Intact margins Assessment should be supported by photography (calibrated with a ruler) where possible. died as compared with 15% of at-risk patients without pressure ulcers. Postdischarge Many factors such as nutrition, mobility, and comorbidities affect healing rates of pressure ulcers. The healing of pressure ulcers requires attention to care and patience for a considerable period of time. Individualized protocols to predict pressure ulcer healing rates have also been developed. In general, a stage II pressure ulcer should heal within 1 2 months in a healthy, mobile, wellnourished older person. eeper stage II and stage III ulcers may take several months to heal. Most stage IV ulcers take more than 6 months to heal. Importantly, pressure ulcers that develop during acute hospitalization are not associated with reduced 1-year survival among high-risk older persons after adjusting for important confounders. MANAGEMENT Treatment The principles of pressure ulcer healing center around three key areas of intervention: pressure management, nutrition optimization, and direct ulcer management. Pressure management includes interventions ranging from improving mobility to special beds that relieve pressure on the area of the wound, while avoiding placing additional areas at risk. Nutrition optimization involves determining and implementing a feeding regimen that the patient can tolerate and that meets their goals of care. irect ulcer management covers the choices of debridement techniques and wound-care products appropriate for the patient s particular Figure 7-2 With good care, even a stage IV pressure ulcer will usually heal. (From Tallis RC, Fillet HM. Brocklehurst s Textbook of Geriatric Medicine and Gerontology, 6th Edition. Churchill Livingstone, 2003.) 3 ulcer. Although care must be individualized to the patients, general guidelines for ulcer management are indicated in Table 7-2 (Fig. 7-2). Initial Support Surface or Bed The initial step in pressure management is to provide an appropriate support surface. There are three basic types of support surfaces: mattress overlays, mattress replacements, and full specialty beds. Mattress overlays may be foam, air, or gel. Mattress replacements may be foam, air, gel, or water. They may be static, alternating air, low air loss, or immersion. Specialty replacement beds are integrated bed systems that can function as do the mattress replacements, and they sometimes provide an integrated rotation feature. While the choices may seem complex, for patients who have a single small stage II ulcer, a static mattress may suffice. However, for those with multiple stage II ulcers, or stage III or IV ulcers, a mattress overlay or specialty mattress is usually required. The alternating pressure feature is especially useful for patients who have little or no healthy turning surfaces such as those with sacral and ischial ulcers. General guidelines for specialty support surface use are indicated in Table 7-3 (Fig. 7-3). Mobility Improving mobility helps to minimize continuous pressure on a single area of the body. Attention must be paid to how long such patients are left on stretchers awaiting tests or on hard operating room tables. Physical or occupational therapists can be very helpful in this regard. Even if patients are bed bound, a bed trapeze may allow patients to reposition themselves without having to wait for nursing staff to do so. Nutrition Management Nutrition management begins with the determination of whether the patient can take oral feeding. If so, he or she should be fed orally; but if not, discussion of nasogastric or gastrostomy tubes should take place. It is important to note that a recent Cochrane review found that it was not possible to draw any firm 3 Management

4 Ch007-X0223.qxd 9/12/2006 6:16 PM Page 4 4 Comprehensive Hospital Medicine: An Evidence Based and Systems Approach Table 7-2 Management of Pressure Ulcers by Stage Ulcer Stage Nutrition Pressure Interventions Wound Care Wound Products Interventions Interventions to Consider Stage I ietitian consult to OT/PT consult for Cleanse with mild Wound covering products: evaluate intake of: positioning soap and water Transparent film Protein Static pressure Carefully, gently pat dressing Calories reduction dry Hydrocolloid sheet Vitamin C Mattress/wheelchair Zinc pad Stage II ietitian consult as As above Cleanse as above Wound covering products above as above Stage III ietitian consult as As above ebride any eschar Wound packing products: above If progressive ulcer or for nonheel ulcers Saline-dampened gauze ulcers on multiple Hydrogel turning surfaces use Alginate low air loss/alternating pressure mattress overlay/bed Stage IV ietitian consult as Low air loss/alternating ebride any eschar Wound packing products above pressure mattress for nonheel ulcers Saline-dampened gauze overlay/bed Evalute for Hydrogel osteomyelitis Alginate Systemic antibiotics if Wound V.A.C. System infection source Surgical consult if extensive debridement or bone biopsy needed Table 7-3 Special Support Surface Use Patient Characteristic Intervention Individuals at risk for pressure ulcers Use static pressure reduction mattress or 4 6 thick foam overlay Patient can assume multiple positions Use static pressure reduction mattress or 4 6 thick foam overlay Can avoid putting weight directly on the pressure ulcer oes not bottom out Patient can assume multiple positions Use a dynamic support surface Can NOT avoid putting weight directly on the pressure ulcer Bottoms out on a static device Patient has multiple stage III or IV pressure ulcers on Use a low air-loss or air-fluidized bed multiple turning surfaces, OR excess moisture is a significant contributing factor to the ulcer Adapted from: Panel for Pressure Ulcer Treatment, Clinical Practice Guideline No. 15. Rockville, Md: US epartment of Health and Human Services, Public Health Service. Agency for Health Care Policy and Research; 1994, AHCPR Publication No (pp 39 41). conclusions on the effect of enteral and parenteral nutrition on the prevention and treatment of pressure ulcers. Vitamin C is usually recommended at a dose of 500 mg BI to help collagen synthesis and tensile strength. Zinc is given at a dose of 220 mg daily to help with protein synthesis, though higher doses may impair healing. There are fewer data to support the routine use of other vitamins and micronutrients such as copper, manganese, and vitamins A and E. A dietician should be consulted for all patients with pressure ulcers. Wound Management The key aspects of direct wound management increase with increasing stage of the ulcer. Ulcers need a clean base to allow epithelial cells to grow and heal the ulcer, so all necrotic tissue must be removed. Appropriate moisture control is key here. Too much moisture leads to maceration of the wound. Excessive dryness leads to chafing. Both can result in further injury and poor epithelia cell growth.

5 Ch007-X0223.qxd 9/12/2006 6:16 PM Page 5 4 Figure 7-3 An alternating pressure mattress overlay. (From Tallis RC, Fillet HM. Brocklehurst s Textbook of Geriatric Medicine and Gerontology, 6th Edition. Churchill Livingstone, 2003.) The goal of cleaning or debridement is to remove the unwanted dead tissue, while preserving the granulation tissue that will heal the wound. If cleaning with gauze or sponges, only slight pressure should be applied to avoid disturbing the wound bed. If irrigating, a syringe and 19-guage angiocath with gentle pulsatile lavage can achieve acceptable low pressures of 4 15 psi, or a commercial system may be used. Ulcers should generally be cleaned only with normal saline; do not use the long list of skin cleansers and antiseptic agents ranging from iodine to sodium hypochlorite solution (akin s solution). Although topical growth factors may speed healing, their role and the most costeffective approach to use is unclear. A description of common products used for wound care is indicated in Table 7-4 (Fig. 7-4). Unless the need for sharp debridement is urgent, mechanical, autolytic, and enzymatic debridement are equally acceptable (Table 7-5). If progressive cellulitis or sepsis is present, sharp debridement should be used and should usually take place within 12 hours, along with a tissue biopsy for culture and sensitivity if systemic infection is suspected. Ulcer cleansing and debridement 5 Management Table 7-4 Wound Products Product Cover Pack Absorb ebride Comments Sample Products Type Ulcer Ulcer Exudate Transparent Yes No Light Light Good to reduce erma Film, OpSite, Polyskin, adhesive friction Tegaderm Adaptic, films May cause further Exu-ry,Telfa,Vaseline damage in thin skin Gauze patients Nonadherent Yes No Light No Good for patients with dressing thin skin Gauze rolls Yes Yes Moderate Yes Allow gauze to dry Various and sponges to heavy if debridement desired, otherwise keep damp between changes Foam sheets Yes No Moderate No Allevyn, Curafoam, Flexzan, to heavy Lyofoam, Mitraflex, Polymem Hydrocolloid Yes No Light to Yes Occlusive. o not use CarraSmart, Combiderm, Sheets moderate if anerobic infection. Comfeel Plus, Cutinova, Monitor closely if ermacol, uoerm, diabetic or imunocompromised Exuderm, Replicare, Restore, Sorbex, Tegasorb, Ultec Hydrogel Yes No Light to Yes Soothes minor burns; Aquaflo, Carraress, sheet moderate has cooling effect Elastogel, NuGel,Vigilon Hydrogel No Yes Light Yes Needs cover dressing. Biolex Gel, Carrasyn Gel, amorphous May macerate intact Curafil, Curasol Gel, gel skin Intrasite, Saf-Gel, Tegagel, Wound res Alginate No Yes (Pads) Moderate No Needs cover dressing. AlgiSite, Calcicare, Curasorb, to heavy Comes in pads and FyBron, Kalginate, ropes. May dessicate wound with light or no exudates Hemostatic properties. Hydrofiber No Yes (Rope only) Moderate Some Vertical wicking Aquacel to heavy reduces maceration Enzymatic No No No Yes May take 1 2 weeks to Accuzyme debrider achieve debridement Kaltostat, Seasorb, Sorbsan, Tegagen

6 Ch007-X0223.qxd 9/12/2006 6:16 PM Page 6 6 Comprehensive Hospital Medicine: An Evidence Based and Systems Approach 5 Table 7-5 ebridement Techniques ebridement Technique for Removal Indications Contraindications Relevant Wound Type of evitalized Tissue Care Products Autolytic Natural Necrotic tissue ry gangrene Include, but not limited to: ry eschar ry ischemic wounds Transparent films Hydrocolloids Hydrogels Alginates Gauze Mechanical Outside force Necrotic wounds Foul odor Include, but not limited to: evitalized tissue Wet to dry dressings Macerated tissue Whirlpool Wound irrigation Enzymatic Topical application of Necrotic wounds Clean wounds Include, but not limited to: specialized protein ry gangrene Accuzyme dry Ischemic Wounds Panafil Hypersensitivity Santyl Sharp Sharp instruments Necrotic wounds Arterial insufficiency Sepsis Gangrene Progressive cellulitis Stable heel ulcers Callus formation Inability to identify structures in wound Figure 7-4 A stage IV pressure ulcer in need of debridement. (From Tallis RC, Fillet HM. Brocklehurst s Textbook of Geriatric Medicine and Gerontology, 6th Edition. Churchill Livingstone ) may also reduce bacterial colonization in stage II IV ulcers. Some stage III or IV ulcers can take a long time to be fully debrided, and frequent treatments may be needed in the presence of purulent drainage or foul odor. Enzymatic products like Accuzyme (papain urea) are effective debridement agents, but they take longer than sharp debridement. Often, they are used with Iodosorb gel or Iodoflex pads (small hydrophilic beads with 0.9% cadexomer iodine) that adsorb bacteria and cellular debris by capillary action, leading to less inflammation and odor. Whirlpool treatment is best for ulcers with heavy slough, exudate, or necrotic tissue and should be stopped when the ulcer is clean. If debridement is associated with bleeding, apply a dry dressing initially, followed by a moist dressing after 8 to 24 hours. 1 Based on expert opinion, stable heel eschar without erythema, edema, or drainage should not be debrided, but needs to be assessed daily for complications that may necessitate debridement. 1 A wide range of products can be applied to ulcers (see Table 7-3). For a typical stage I ulcer, one should protect the skin; and reduce pressure, shear, and friction. For a stage II ulcer, one should additionally protect and hydrate the wound. A stage III ulcer further requires debridement as necessary. A stage IV ulcer requires all of the above, as well as obliteration of dead space. In grade III or IV pressure ulcers, treatment using first alginate and then hydrocolloid dressing yields more rapid improvement that hydrocolloid alone. Pain control is also critical, and patients with pressure ulcers report pain and tend to receive inadequate analgesia, perhaps due to the false belief that stage III IV pressure ulcers are painless due to nerve fiber destruction. The treatment of skin tears is a bit more straightforward, but follows the principles of pressure ulcer management. The size of the tear shoud be documented along with a drawing if helpful. In general, the area should be gently cleaned with normal saline and allowed to air dry or dry by gentle patting. The skin flap should be approximated and held in place with either Steri-Strips or a moist nonadherent dressing. Clear film dressings are acceptable, but care must be taken when removing the dressing to avoid further skin injury or reinjury. An arrow drawn on the dresssing that identifies the direction of the skin tear can help in this regard. Although it is important for the hospital physician to understand the basic tenets of pressure ulcer management, it is equally important that physicians understand the components of a Skin Integrity team. Such teams are typically composed of a nurse who has advanced training in wound care (Skin Clinical Nurse Specialist), a nutritionist, and a therapist. The nurse will typically advise on local wound care measures and assist in selecting from the hundreds of available skin products according to the patient s need and hospital formulary. A nutritionist is important to ensure that negative nitrogen balance is avoided, and to advise on the type, route, and composition of feeding. Finally, a therapist (in some places this will be a Physical Therapist and in others an Occupational Therapist) is essential to advise on positioning techniques, pressure reduction devices, and optimization of mobility.

7 Ch007-X0223.qxd 9/12/2006 6:16 PM Page 7 Subsequent Care One should expect to see signs of healing in a clean ulcer by 2 4 weeks. An accurate skin assessment must be performed and documented when patients are transferred to other health care facilities. For patients being discharged to home, visiting nurse services skilled in pressure ulcer management should be arranged, along with any special equipment, including hospital bed, special support mattresses, and lifts. Caregivers should be instructed on wound care and turning procedures prior to discharge of the patient. If a clean ulcer on an inpatient has persistent exudate and/or shows no signs of healing despite optimal care for 2 4 weeks, then a 2-week trial of topical antibiotics should be considered. A culture is usually not needed, as culture results are not likely to alter the treatment since these infections typically do not involve deep tissue invasion. Vacuum-assisted closure is a reasonable intervention for large chronic pressure ulcers. Color photos taken on initial assessment and reevaluation are helpful in monitoring changes in the ulcer as long as the photo accurately depicts the appearance of the ulcer. The appropriate role of various growth factors in speeding healing is the subject of active investigation. Operative intervention is a last resort and should take place after a careful analysis of risks and benefits. Important factors to consider are medical stability, prognosis, nutritional status, risks of blood loss, postoperative immobility, quality of life, treatment goals, patient preferences, and risk of recurrence. Because smoking, spasticity, bacterial colonization of wound, and incontinence may impair wound healing, these should be addressed before surgical intervention. PREVENTION Pressure ulcer prevention shares similarities with pressure ulcer treatment. Important keys to pressure ulcer prevention can be found in Box 7-2. Important aspects include staff education. This 7 Prevention Box 7-2 Keys to Pressure Ulcer Prevention 1. Staff Education A. Focus on nurses and nursing assistants. i. Clear Assessment Expectations a. Complete skin assessment on admission b. Complete skin assessment every 48 hours c. Complete skin assessment whenever the patient s condition significantly changes ii. Clear ocumentation Expectations a. Assessment with reliable and standardized tool such as Braden or Norton Scales iii. Clear Action Expectations a. Triggered prevention protocols implemented within 12 hours b. Communication with physician regarding assesment and protocol implementation c. Home caregiver instruction 2. Pressure management A. Patient-Centered i. Keeping the patient as active as possible ii. Instruction patient to perform small weight shifts every 15 minutes when able iii. Limit head of bed elevation to no more than 30 degrees iv. Trapeze to assist with self-mobility B. Caregiver Centered i. Turn every 2 hours if consistent with overall care goals ii. Hourly repositioning of chair or wheelchair bound patients iii. Always use transfer sheet to move the patient C. Material-Centered i. Special support surface such as thick foam or static pressure mattress ii. Cushions to keep bony prominences from direct contact with each other iii. Cushions or devices to raise heels of bedbound patients off the bed iv. Protect the patient s elbows, heels, sacrum, and back of the head if he where exposed to friction v. Heel and elbow protectors vi. No Massage of reddened bony prominences vii. No donut devices 3. Moisture Management A. Treat Excess moisture i. Identify source ii. Regular use of a bedpan or urinal iii. Cleaning the skin quickly after any soiling iv. Absorbent pads that wick moisture v. Barrier dressings or creams B. Treat excess dryness i. Lotion use after bathing ii. No hot water iii. No drying soaps 4. Nutrition management 1. Assure adequate nutrition i. ietitian consultation if at risk ii. Increase protein, calorie, and/or vitamin intake as needed. iii. Give a cup of water given with the turning schedule to maintain hydration iv. Monitor NPO status due to multiple tests v. Peripheral parenteral nutrition (PPN) if NPO over several days

8 Ch007-X0223.qxd 9/12/2006 6:16 PM Page 8 8 Comprehensive Hospital Medicine: An Evidence Based and Systems Approach Figures 7-5, 7-6 The heels and greater trochanter are common sites for the development of pressure ulcers. (From Tallis RC, Fillet HM. Brocklehurst s Textbook of Geriatric Medicine and Gerontology, 6th Edition. Churchill Livingstone, 2003.) includes proper use, documentation, and implementation of protocols based on assessment tools such as the Braden or Norton Scales. For example, factors assessed by the Braden Scale include sensory perception, moisture, activity, mobilty, nutrition, friction, and shear. Braden scale scores range from 0 23, with increased risk indicated by a score of 18 or below for elderly and persons with darkly pigmented skin, and 16 or below for other adults. Other helpful prevention techniques indicated in the Agency for Healthcare Research and Quality (AHRQ) prevention recommendations 1 target the key areas of pressure management, moisture management, nutrition management, and friction/shear minimization (Figs. 7-5, 7-6). The heels are an area of special risk. Preventive heel precautions include assessment of the feet twice daily. Use of a transparent film, hydrocolloid dressing, or even socks can minimize friction. Heel pressure can be removed through the use of pillows, blanket rolls, or heel lift devices. Active and/or passive range of motion of the ankle can be achieved through ankle movements twice daily. For patients not able to place the ankle in neutral position easily, occupational or physical therapy consultation is helpful. For skin tears, prevention consists of the basic principles of pressure ulcer prevention. In addition, high-risk patients can wear long sleeves or pants to protect their extremities. Adequate lighting reduces the risk of bumping into furniture or equipment. A safe area for wandering should be provided if possible. Nursing assistants need to understand how to protect patients from selfinjury or injury during routine care and turning. angling arms and legs should be supported with pillows or blankets. Padding equipment, such as wheelchair arm and leg supports, offers additional protection from accidental injury. Elderly, frail skin should have only nonadherent dressings, and only paper tape should be used on the skin. Gauze wraps, stockinettes, or other wraps that can be taped to themselves to secure dressings are useful in frail patients. CLINICAL ALGORITHM(S) There are many studies and protocols suggested for use in longterm care facilities, and algorithms specific to the inpatient setting appear to be based on these. The AHRQ guidelines on pressure ulcer prevention and treatemnt of pressur ulcers are available online at ISCHARGE/FOLLOW-UP PLANS For patients returning home, appropriate support surface should be arranged, and Visiting Nurse referral made. For complicated ulcers, a Skin Clinical Nurse Specialist should be specifically requested. A wound clinic referral, when available, is a useful adjuvant for difficult ulcers. For patients being transferred to another facility, pressure ulcer location, depth, size, stage, and treatment should always be documented in the transfer records. Patient Education Patient educational should address basic information such as the etiology and risk factors for pressure ulcers, and the basics of skin assessment. If a special support surface is needed, home caregivers should be instructed on its use as well as positioning techniques. The use of lifts, transfer sheets, and wound-care techniques also must be clearly explained. Outpatient Physician Communication It is best if the outpatient physician contact information be provided to the home health agency and wound clinic so the primary care provider can assume management of the ulcer after discharge. The Primary Care provider, however, must be provided information regarding the stage, size, and treatment plan for the ulcer, as well as contact information for the home health agency and wound clinic that will be providing assistance with ulcer management.

9 Ch007-X0223.qxd 9/12/2006 6:16 PM Page 9 Key Points Stage 1 pressure ulcers identify at risk areas that have not broken down yet. Pressure ulcers most commonly occur over areas of bony prominences. An ulcer appearing on a part of the body that does not have a source of frequent constant pressure is probably not a pressure ulcer. The principles of pressure ulcer healing center around three key areas of intervention: pressure management, nutrition optimization, and direct ulcer management. 11. Langer G. Schloemer G. Knerr A, et al. Nutritional interventions for preventing and treating pressure ulcer. Coch atabase Syst Rev 2003; (4):C Thomas R. The promise of topical growth factors in healing pressure ulcers. Ann Intern Med 2003; 139(8): Belmin J, Meaume S, Rabus M, et al. Sequential treatment with calcium alginate dressings and hydrocolloid dressings accelerates pressure ulcer healing in older subjects: a multicenter randomized trial of sequential versus nonsequential treatment with hydrocolloid dressings alone. J Am Geriatr Soc 2002; 50: Cullum N, eeks J, Sheldon TA, et al. Beds, mattresses & cushions for pressure sore prevention & treatment (Cochrane Review). In: The Cochrane Library, 2, Oxford Update Software; ow G. Bacterial swabs and the chronic wound: when, how, and what do they mean. Ostomy Wound Manage 2001; 49(5A, suppl): Argenta LC, Morykwas M. Vacuum-assisted closure: A new method for wound control and treatment: clinical experience. Ann Plast Surg 1997; 38:(6): Bergstrom N, Braden BJ, Laguzza A, et al. The Braden Scale for predicting pressure sore risk. Nurs Res 1987; 36(4): Norton, McLaren R, Exton-Smith AN. Pressure Sores: An Investigation of Geriatric Nursing Problems in Hospital. New York: Churchill Livingstone, Suggested Reading The Hospital s Skin Integrity Team should be utilized early on as collaborators in the care and management of patients with pressure ulcers. Standardized assessment tools should be routinely used to identify patients at increased risk for pressure ulcers. REFERENCES SUGGESTE REAING 1. Agency for Health Care Policy & Research.Panel for Pressure Ulcer Treatment, Clinical Practice Guideline Number 15. Rockville, M. US epartment of Health & Human Services. Public Health Service. AHCPR Publication No ; 1994:1. 2. The National Pressure Ulcer Advisory Panel (NPUAP); Cuddigan J, Ayello EA, Sussman C, editors. Pressure Ulcers in America: Prevalence, Incidence and Implications for the Future. NPUAP. Reston,VA, Amlung SR, Miller WL, Bosley LM. The 1999 national pressure ulcer prevalence survey: a benchmarking approach. Adv Skin Wound Care 2001; 4(6): Payne RL, Martin ML. efining and classifying skin tears: need for a common language. Ostomy Wound Manage 1993; 39(5):16 20, 22 24, George S, Bugwadia N. Nutrition & wound healing. Med Surg Nurs 1996; 5(4): Livesley NJ, Chow AW. Infected pressure ulcers in elderly individuals. Clin Infect is 2002 ec; 1;35(11): Epub Han H, Lewis VL Jr, Wiedrich TA. The value of Jamshidi core needle bone biopsy in predicting postoperative osteomyelitis in grade IV pressure ulcer patients. Plastic Reconstr Surg 2002; 110(1): Allman RM, Laprade CA, Noel LB, et al. Pressure sores among hospitalized patients. Ann Intern Med 1986; 105: Wallenstein S. Brem H. Statistical analysis of wound-healing rates for pressure ulcers. Am J Surg 2004; 188(1A Suppl): Thomas R. Goode PS. Tarquine PH, et al. Hospital-acquired pressure ulcers and risk of death. J Am Geriatr Soc 1996; 44(12): Amlung SR, Miller WL, Bosley LM. The 1999 national pressure ulcer prevalence survey: a benchmarking approach. Adv Skin Wound Care 2001; 14(6): Livesley NJ, Chow AW. Infected pressure ulcers in elderly individuals. Clin Infect is 2002; 35(11): Epub Wallenstein S, Brem H. Statistical analysis of wound-healing rates for pressure ulcers. Am J Surg 2004; 188(1A Suppl): Thomas R, Goode PS, Tarquine PH, et al. Hospital-acquired pressure ulcers and risk of death. J Am Geriatr Soc 1996; 44(12): Langer G, Schloemer G, Knerr A, et al. Nutritional interventions for preventing and treating pressure ulcer. Coch atabase Syst Rev 2003; (4):C Thomas R. The promise of topical growth factors in healing pressure ulcers. Ann Intern Med 2003; 139(8): Belmin J, Meaume S, Rabus M, et al. Sequential treatment with calcium alginate dressings and hydrocolloid dressings accelerates pressure ulcer healing in older subjects: a multicenter randomized trial of sequential versus nonsequential treatment with hydrocolloid dressings alone. J Am Geriatr Soc 2002; 50: Cullum N, eeks J, Sheldon TA, et al. Beds, mattresses & cushions for pressure sore prevention & treatment (Cochrane Review). The Cochrane Library, 2, Oxford Update Software; ow G. Bacterial swabs and the chronic wound: When, how, and what do they mean. Ostomy Wound Mgt 2001; 49(5A, suppl):8 13. Argenta LC, Morykwas M. Vacuum-assisted closure: A new method for wound control and treatment: clinical experience. Ann Plast Surg 1997; 38(6): Bergstrom N, Braden BJ, Laguzza A, et al. The Braden Scale for predicting pressure sore risk. Nurs Res 1987; 36(4):

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