Best Practice in Prevention and Treatment of Pressure Ulcers. Objectives. Accreditation Canada Sheila Moffatt

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1 Best Practice in Prevention and Treatment of Pressure Ulcers Sheila Moffatt RN BN CRN(c) IIWCC Pressure Ulcer Prevention Coordinator Objectives Discuss Accreditation Canada Required Organizational Practices (ROP) Discuss the Best Practice Guidelines available for prevention and treatment of pressure ulcers (NPUAP, CAWC and RNAO) Discuss the risk factors and assessment considerations related to pressure ulcers Review prevention strategies Review Pressure Ulcer Staging as outlined by NPUAP (Feb 2007) Review treatment options for pressure ulcers. Accreditation Canada 2015 The team assesses each client s risk for developing a pressure ulcer and implements interventions to prevent pressure ulcer development. Accreditation ROP Handbook, p

2 Pressure Ulcer Prevention 1.The team conducts an initial pressure ulcer risk assessment at admission, using a validated, standardized risk assessment tool. 2.The team reassesses each client for risk of developing pressure ulcers at regular intervals, and with significant change in client status. 3.The team implements documented protocols and procedures based on best practice guidelines to prevent the development of pressure ulcers, which may include interventions to: prevent skin breakdown; minimize pressure, shear, and friction; reposition; manage moisture; optimize nutrition and hydration; and enhance mobility and activity. 4.The team supports education for health care providers, clients, and families or caregivers on the risk factors and strategies for the prevention of pressure ulcers. 5.The team has a system in place to measure the effectiveness of pressure ulcer prevention strategies, and uses results to make improvements. ROP Handbook 2015 Skin and Wound Care * For the Home Care Services Standards. The organization uses an interprofessional and collaborative approach to assess clients who need skin and wound care and provide evidenceinformed care that promotes healing and reduces morbidity and mortality. ROP Handbook 2015 International Pressure Ulcer Guidelines Oct 16,

3 RNAO Best Practice Guidelines Canadian Association of Wound Care Society of Actuaries (SOA) Conducted a claims-based study listing the 10 most expensive types of medical errors in the US. Pressure Ulcers are #1 374,964 errors $10,288 per error $3.858 billion total

4 U.K. study monthly costs $2450 Uncomplicated Stage I $3230 Stage IV $3616 Complicated Stage II with critical colonization to $4003 Stage III / IV $12,658 Complicated Stage II to IVwith osteomyelitis Bennett G, Dealy C and Posnett J. The cost of pressure ulcers in the UK. Age and Ageing. 2004;33(3): Brem et al, 2010 RESULTS: The average hospital treatment cost (9 patients) associated with stage IV pressure ulcers and related complications was $129,248 for hospital-acquired ulcers during 1 admission, and $124,327 for community-acquired ulcers over an average of 4 admissions. Gail Woodbury and Pamela Houghton (2004) indicated that the prevalence of pressure ulcers in Canada was 25% in acute care, 30% in non-acute care, 22% in mixed health-care settings, and 15% in community care Result-patient suffering, caregiver anguish, extra work for health-care providers, and millions spent in health-care dollars needlessly 4

5 Pressure Ulcer Prevention Program Team Tools Policy Policies Unit Routines Education + Team Risk Assessment Prevention Strategies Documentation Tools Best Practice Guidelines System Practices Product Knowledge Patient Centered Concerns Management Support Quality of Life Patient Assessment Health history and physical assessment History of skin breakdown Psychosocial issues Causative/risk factors 5

6 Intrinsic Risk Factors Age Nutrition Disease Process Drug Therapy Lack of Sensation Ortho Deformities Smoking Immobility History of ulcers Obesity Infection Impaired circulation Incontinence Dehydration Excessive body heat Cognition Extrinsic Risk Factors External Physical Forces Pressure Shear Internal movement Friction External movement Moisture Heat Risk Assessment Tools Standard Assessments must be implemented in all care facilities Must be a valid and reliable tool Examples: Braden, Norton, Waterlow, or SCIPUS 6

7 TOTAL SCORE RISK FACTOR SCORE / DESCRIPTION ASSESSMENT: Sensory 1.Completely Limited: 2.Very Limited: Responds only 3.Slightly Limited: Responds Perception: Unresponsive (does not moan flinch, to painful stimuli Cannot to verbal commands but cannot Ability to respond or grasp) to painful stimuli due to communicate discomfort expect always communicate discomfort meaningfully to diminished level of consciousness or by moaning or restlessness OR or need to be turned. OR Has pressure related sedation OR limited ability to feel has a sensory impairment which some sensory impairment discomfort pain over most of body limits the ability to feel pain or which limits ability to feel pain discomfort over ½ of body. or discomfort in1 or 2 extremities Moisture: 1.Constantly Moist: 2.Often Moist:: 3.Occasionally Moist: Degree to which skin Skin is kept moist almost constantly Skin is often but not always Skin is occasionally moist is exposed to by perspiration, urine etc. Dampness moist. Linen must be changed at requiring an extra linen change moisture is detected every time patient is least once a shift. approximately once a day. moved or turned. Activity: 1.Bedfast: 2.Chairfast: 3.Walks Occasional: Degree of physical Confined to bed. Completely Ability to walk severely limited or Walks occasionally during day activity immobile. Does not make even slight non-existent. Cannot bear own but for very short distances, changes in body or extremity position weight and/or must be assisted with or without assistance. without assistance. into chair or wheelchair. Spends majority of each shift in bed or chair. Mobility: 1.Completely Immobile: 2.Very Limited: 3.Slightly Limited: Ability to change and Does not make even slight changes Makes occasional slight Makes frequent though slight control body in body or extremity position without changes in body or extremity changes in body or extremity position. assistance. position but unable to make position independently. frequent or significant changes independently. Nutrition: 1.Very Poor: 2.Probably Inadequate: 3.Adequate: Usual food intake Never eats a complete meal. Rarely Rarely eats a complete meal Eats over half of most meals. pattern. eats more than 1/3 of any food and generally eats only about ½ Eats a total of 4 servings of offered. Eats 2 servings or less of of any food offered. Protein protein (meat, dairy products) protein (meat or dairy products) per intake includes only 3 servings each day. Occasionally will day. Takes fluids poorly. Does not of meat or dairy products per refuse a meal but will usually take a liquid dietary supplement. OR day. Occasionally will take a take a supplement if offered. is NPO and/or maintained on clear dietary supplement. OR OR is on a tube feeding or TPN liquids of IV s for more than 5 days. receives less than optimum regimen which probably meets amount of liquid diet or tube most of nutritional needs. feeding. Friction and Shear: 1.Problem: 2.Potential Problem: 3.No Apparent Problem: Requires moderate to maximum Moves feebly or requires Moves in bed and in chair assistance in moving. Complete minimum assistance. During a independently and has lifting without sliding against sheets is move skin probably slides to sufficient muscle strength to lift impossible. Frequently slides down in some extent against sheets, up completely during move. bed or chair requiring frequent chair, restraints or other Maintains good position in bed repositioning with maximum devices. Maintains relatively or chair at all times. assistance. Spasticity contractures or good position in chair or bed agitation lead to almost constant most of the time but friction. occasionally slides down. 4.No Impairment: Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. 4.Rarely Moist: Skin is usually dry, linen only requires changing at routine intervals. 4.Walks Frequently: Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours. 4.No Limitation: Makes major and frequent changes in position without assistance. 4.Excellent: Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation Braden Score SENSORY Ability to respond meaningfully to pressure related discomfort MOISTURE Degree to which skin is exposed to moisture ACTIVITY Degree of physical activity MOBILITY Ability to change and control body position NUTRITION / HYDRATION Usual food intake pattern FRICTION AND SHEAR Sensory- Ability to respond meaningfully to pressure related discomfort Is there changes in sensation due to neurological deficits, changes in cognition, sedation or medication? Sensation of light touch Sensation of deep/hard touch Sensation of heat or cold Sensation of pressure 7

8 Interventions Ensure the patient s skin is assessed more frequently due to inablility to feel Ensure there is plan of care to turn and offload bony prominences Increase frequency of turns, offload with pillows/wedges or consider a new surface if the patient is starting to have red areas with or without blanching Moisture- Degree to which skin is exposed to moisture. Is the patient moist constantly, often, occasionally or rarely? perspiration wound drainage Incontinence fever Interventions Investigate the source of the moisture Keep the body clean and dry Elderly skin requires warm water, ph balanced, fragrance free and or no alcohol Establish bowel and bladder program Use protective barrier film, spray or cream Surface support with microclimate 2011 Recommendation 3.8 8

9 Activity- Degree of physical activity Bedfast- Are they confined to bed? Chairfast- Are they dependant for transfer to wheelchair and spend time in a chair? Walking- Are they able to weight bear or walk? Interventions Ensure skin is assessed once a patient returns to be. Evaluate the skin after being in a chair to ensure the patients skin is tolerating the activity Use mobility strategies if Bedfast Mobility- Ability to change and control body position Completely immobile, very limited, slightly limited or not limited in bed mobility. As the patient is less able to change position in bed, the more at risk he/she will be to have pressure areas 9

10 Pressure Pressure Pressure = Force/Area Capillary closing pressure mm Hg Minimize peak pressures Redistribute pressures Interventions Implement turning schedules Maintain HOB less than side lying in bed Use turning sheets and trapeze bars Patients should shift their weight every 15 minutes if able (RNAO) 10

11 Keep heels free off the surface of the bed International Guidelines 2014 Nutrition- Usual food intake pattern Is the patients nutritional intake poor, inadequate, adequate, or excellent? Do they eat any of there food, or NPO? Do they eat 1/3, 1/2, or all of their meal? How many servings of meat and dairy (protein) do they eat? Do they drink nutritional supplements? Do they drink adequate fluids Interventions Dietary assessment/management -weight -lab values -calorie intake/count -clinical indicators Assess/correct dehydration 11

12 Nutrition Support cont d Maximize nutritional status and screen for: - pre-albumin, serum albumin -HBA1C (<7.0) - absolute lymphocyte count ( 1.5x10⁹) - Hgb (<100) -BUN, Cr -TSH -Zinc, Vitamin C, Protein, and Vitamin A Friction and Shear Can the patient lift their bottom off the sheets or are they constantly sliding their skin against the sheets? Does the patient sit with their head of the bed above 30 degrees frequently or all the time? Friction and Shear virtualmedicalcentre.com Shear 12

13 Interventions Use a mechanical lift for transfers Use turning sheet to lift buttock instead of drag on sheets or trapeze Reduce the head of the bed to lower than 30 degrees Encourage the patient to keep the head of the bed down as much as possible Mobilize as soon as possible Therapeutic Support Surfaces 1. Non-powered Air, fluid or foam (overlay or mattress replacement system) e.g. ROHO, V4 foam with ROHO. Therapeutic Support Surfaces 2. Powered Alternating Pressure Mattress Low Air Loss Mattress Low Air Loss and Rotational Mattress 13

14 Seating Assessment Seating/Wheelchair assessment is completed by an occupational therapist. Specialty seating is available at the NSRC for complex needs. At Risk (15 18)* Frequent turning Maximal remobilization Protect heels Manage moisture (see A), nutrition (see B) and friction, and shear (see C). Pressure-reduction support surface if bed- or chairbound * If other major risk factors are present (advanced age, fever, poor dietary intake of protein, diastolic pressure below 60, hemodynamic instability), advance to next level of risk. BRADEN RISK ASSESSMENT SCORE Moderate Risk (13 14)* Turning schedule Use foam wedges for 30 lateral positioning Pressure-reduction support surface Maximal remobilization Protect heels Manage moisture (see A), nutrition (see B) and friction, and shear (see C). ** If other major risk factors are present, advance to next level of risk. High Risk (10 12) Increase frequency of turning Supplement with small shifts Pressure reduction support surface Use foam wedges for 30 lateral positioning Maximal remobilization Protect heels Manage moisture (see A), nutrition (see B) and friction, and shear (see C). Very High Risk (9 or below) All of the actions to the left under (10 12) plus Use pressure-relieving surface: If patient has intractable pain or Severe pain exacerbated by turning or Additional risk factors Low air loss beds do not substitute for turning schedules. Braden Score *If other major risk factors are present: advanced age (75years and older), fever, poor dietary intake of protein, diastolic pressure below 60, hemodynamic instability), advance to next level of risk. 14

15 Patient-Centered Concerns Pain Quality of Life Caregiver/ family concerns Adherence to plan of care Pain Scale 15

16 Quality of Life and Lifestyle Has the patient been involved in the plan? Is this what the patient wants and values? Adherence to the plan developed? Can they stop smoking, maintain diabetic diet, or continue destructive habits? Caregiver/Family Concerns Who will give the care? How will it be delivered? Is it reasonable or have we set the family up to fail? Is there unrealistic expectations of a member of the family? 16

17 History Psycho social Type of Wound Etiology Pressure Stage Pain Wound Assessment Depth, area, size Wound bed Peri wound Odour Exudate Infection MEASURE: a framework for Wound Assessment M Measure/Staging E Exudate A Appearance S Suffering U Undermining R Reevaluate E Edge Keast et al, 2004 Appendix J, RNAO Measure wound parameters length greatest length width greatest width, perpendicular to the greatest length (L x W = Area) depth correlates with the degree of tissue damage 17

18 Superficial infection N Non-healing wounds E Exudating wounds R Red and bleeding granulation tissue D Debris on wound surface (yellow/black) S Smell Deep infection S Size bigger T Temperature increased Os (probe to bone) or exposed N New or satellite areas of breakdown E Exudate, oedema, erythema S Smell What is a Pressure Ulcer? A 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. NPUAP 2007 Staging Pressure Ulcers Pressure ulcers are staged according to the degree of tissue damage observed. Stages include areas of Suspected Deep Tissue Injury, Stages I-IV and Unstageable wounds. *do not stage backwards NPUAP

19 Deep Tissue Injury Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. NPUAP 2007 DTI Stage I Intact skin with non-blanchable redness of a localized area Individuals with darker skin: discoloration, warmth, edema, or firmness NPUAP

20 Stage II Partial-thickness loss of dermis presenting as a shallow open ulcer with a pink red wound bed, without slough. Intact or open/ruptured serum-filled blister NPUAP 2007 Stage III Full-thickness tissue loss Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. NPUAP 2007 Stage IV Full-thickness skin loss with exposed bone, tendon, or muscle. Slough or eschar may be present Often includes undermining & tunneling NPUAP

21 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 *considered unstageable until the base of the wound is revealed NPUAP 2007 Exudate Quantity Quality Odor Quality Serous clear to yellow, thin and watery, usually odorless Serosanguinous pink to light red, thin, watery, usually odorless Sanguinous bright red, bloody Seropurulent cloudy, yellow to tan in color, possibly foul odor Purulent - thick, white to cream, possibly foul odor Keast et al,

22 Odor Amount of odor Type Assessment Scale (with dressing in place): No odor at close range Faint odor at close range Moderate odor in room Strong odor in room Appearance Black necrotic tissue or eschar, soft and wet, or hard and dry. Yellow fibrous tissue (firm) or slough (loose and stringy), yellow to gray-green Red moist, firm and pebbled Pink pink, white or translucent Estimate % of tissue type in the wound bed Suffering Pain history and assessment Pain type noncyclic acute, cyclic acute, chronic wound pain (Nociceptive or neuropathic) Pharmacologic interventions local anesthesia, systemic analgesia, antidepressnants Nonpharmacologic interventions 22

23 Undermining Internal wound area undermining, tunnels, sinus tracts measure both depth and extent Use a clock system, with 12:00 o clock representing the head Trochanter Ulcer with undermining Reevaluate Monitor- infection or deterioration, at each dressing change Reevaluation assess to determine progress toward healing, reassess weekly 23

24 Edge Wound edge- attachment or lack of, undermining, ulcer shape, edge configuration Periwound induration, inflammation, maceration Sloughy Pressure Ulcer with undermining Periwound 24

25 Debridement Autolytic Mechanical Enzymatic Surgical RNAO 2009 Recommendation 3.2 Debridement Goals of treatment Lower extremity vascular assessment Client s condition Type, quantity and location of necrotic tissue The depth and amount of drainage Availability of resources 25

26 Bacterial Balance Contaminated No Signs & Symptoms Colonized +/- Signs & Symptoms Critically Colonized N onhealing E xudative R ed and bleeding D ebris S mell or odor Infected S ize of wound ed T emperature O steomyelitis N ew areas of breakdown E xudate, erythema and edema S mell or odor Host Resistance Topical therapy +/- Systemic therapy Topical therapy Systemic therapy Bacterial Balance Contamination Bacterial colonization Infection Swab technique Topical antimicrobials Topical antiseptics Signs of Infection Pain Erythema Edema Purulent discharge Increased heat Delayed healing Friable 26

27 Moisture Balance How much exudate? What type of drainage? What can control the moisture? Periwound Undermining Tunnelling Maceration Redness Edges Hydrogels Films Hydrocolloids Foams Calcium Alginates Hydrofibre Contact Layers Basic Dressings 27

28 Antimicrobial dressings Reduce bacterial burden in heavily exudating wounds Antimicrobial including pseudomonas, MRSA, VRE Examples: Silver, iodine, honey, and polyhexamethylene biguanide (PHMB) Adjunctive Therapies Electronic Stimulation Ultraviolet light C Warming Therapy Growth factors Skin equivalents Negative pressure wound therapy Hyperbaric oxygen Recommendation 3.6b, RNAO Multi-Disciplinary Approach Working knowledge of prevention and tx Consult other team members (Nutrition, Speech, OT, PT, Dr) Consistent communication Client/Caregiver education/goals 28

29 Education References European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel; European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel; Posthauer ME, Jos MGA. Nutritional strategies for pressure ulcer management. Chapter In: Krasner DL, Rodeheaver GT, Sibbald RG, et al. eds. Chronic wound care: a clinical source book for health professionals. Vol 1. 5th ed. Malvern, PA: HMP Communications, 2012; In press. Registered Nurses' Association of Ontario (RNAO). Risk assessment & prevention of pressure ulcers. Guideline supplement. Nursing best practice guideline. Toronto, ON: Registered Nurses' Association of Ontario; 2011 Sep. Registered Nurses' Association of Ontario (RNAO). Assessment and management of stage I to IV pressure ulcers. Summary of recommendations. Nursing best practice guideline. Toronto, ON: Registered Nurses' Association of Ontario; 2007 revision. Keast D, Parslow N, Houghton PE, et al. Best practice recommendations for the prevention and treatment of pressure ulcers: update Wound Care Canada. 2006;4(1): Sibbald RG, Goodman L, Woo KY, et al. Special considerations in wound bed preparation 2011: an update(c). Adv Skin Wound Care Sep;24(9): Woodbury, M. G. & Houghton, P. E. (2004). Prevalence of pressure ulcers in Canadian healthcare settings. Ostomy.Wound.Manage., 50,