PRESSURE ULCERS IN THE NURSING HOME

CLINICAL PRACTICE GUIDELINE

 

DISEASE RECOGNITION/STAGING CRITERIA

Skin injury due to sustained pressure, usually over a bony prominence

Staged:
  1. Nonblanchable erythema of intact skin
  2. Partial thickness skin loss involving epidermis or dermis; presents as abrasion, blister or shallow crater
  3. Full thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia; presents as deep crater with or without undermining of adjacent tissue
  4. Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures. May have undermining sinus tract.

Unstaged:

Closed pressure ulcer: Large bursa-like walled off cavity lined by chronic fibrosis extending

to deep fascia or bone. Drainage through small sinus tract.

CONTEXT / / COMMUNICATION

Most nursing home residents have multiple risk factors associated with development of pressure ulcers. All pressure ulcers have the potential to increase morbidity and mortality. The Department of Health Surveyors considers a pressure ulcer, in a resident considered to be at low risk, a Sentinel Event. For all these reasons skin evaluations, risk assessments, prevention and treatment plans are always appropriate. If the resident is moribund or terminally ill, or if a workup would not change management, or if the resident or responsible party refuses a workup, then a conservative, palliative approach is appropriate. The facility nurse should regularly communicate with the responsible party on the skin management plan, with MD or NP follow-up as needed.

ASSOCIATED RISKS

  • Diseases: HF, DM, PVD (especially with ABI < 0.5), neuropathy, immunodeficiency, ESRD, infections, degenerative neurological disorder, depression, anemia
  • Extrinsic factors: pressure, friction, moisture, shear, restraints, bedfast
  • Intrinsic factors: impaired nutrition or hydration, incontinence, lack of independent movement, sensory loss, immobilization, contractures, previous pressure ulcer
  • Iatrogenic factors: corticosteroids, radiation, chemotherapy, drugs affecting alertness and mobility

 

PHYSICAL EXAMINATION

  • Comprehensive physical examination including skin assessment, risk assessment, staging of pressure ulcers with measurements, notation of healed pressure areas

 

DIAGNOSTIC WORK-UP

  • Labs: CBC with diff, CMP (includes albumin), TSH, ESR (if infection or osteomyelitis)
  • X-ray (if osteomyelitis)
  • Culture ONLY when infection suspected (heavy exudates) or a clean but not healing ulcer
  • Arterial Doppler if ulcer on lower extremity. ABI < 0.5 predictor of poor healing and reoccurrence.

 

TREATMENT/PREVENTION OPTIONS

Principles of treatment:

  1. Remove dead tissue through sharp surgical debridement, whirlpool, enzymatic topical or moist to dry dressing. DO NOT remove eschar on heel unless fluctuant or infected. Discontinue debridement when granulating tissue present.
  2. Control level of bacteria through cleansing and with irrigation of deeper ulcers.
  3. Eliminate dead space with packing.
  4. Control exudates with appropriate dressings.
  5. Provide moist healing environment.
  6. Use oral antibiotics ONLY in presence of spreading cellulitis, sepsis, osteomyelitis, (odor, purulent exudate, increase in size, fever, large peri-ulcer erythema) [Levaquin & Flagyl for a minimum of two weeks, longer if good response.]
  7. Support nutritional status.`

Principles of prevention:

  1. Relieve of pressure – specialized beds, cushions, positioning devices
  2. Eliminate skin moisture – consider indwelling foley catheter for stage III or IV
  3. Reduce friction and shear
  4. Improve nutrition and hydration
  5. Discontinue offending medications where possible
  6. Manage disease risk factors
  7. Involve appropriate disciplines (dietary, podiatry, PT/OT, dermatology, physiatry, surgeons, enterostomal nurses)
  8. Consider risk assessment scales (Braden, Norton)

 

WOUND CARE

Product

Type (examples)

Drainage

Ulcer stage

Comments

Light

Mod

Heavy

I

II

III

IV

Cleansing –

Basis/Dove soap

 

    

 

X

      

Pat dry. Do not massage. Relieve of pressure alone might heal.

Normal saline

X

      

X

      

Normal Saline

irrigation

X

X

X

    

X

X

If necrosis present debride necrotic tissue first.

Products-

Protectant: Selan,

A&D, Granulex, Dermagram

      

 

X

        

Topical antibiotics – TAO, Bactroban, Silvadene

 

X

 

 

  

 

 

X

 

X

 

X

 

X

Use ONLY for signs of local infection at ulcer edge. Use ONLY for two weeks. Watch for local irritation from product.

Enzymatic debriders –

Elase, Santyl

 

 

 

 

 

    

 

X

X

Use only for chemical debridement of eschar and discontinue when eschar eliminated. Protect surrounding tissue.

Dressings -Transparent films: Op-Site, Tegaderm

 

X

    

 

X

 

X

    

Change Q 5-7 days.

Provides autolytic debridement of slough.

Hydrocolloids:

Duoderm, Comfeel, Replicare

 

X

 

X

 

 

 

 

 

 

 

X

 

X

  

Change Q 3-5 days.

Provides autolytic debridement of slough. Can apply over alginate to control drainage.

Absorbents-

Alginates: Sorbsan, Algiderm

 

 

 

 

X

 

X

  

 

X

 

X

 

X

Apply within ulcer borders.

Requires cover dressing. Protect surroundings skin with Vaseline.

Hydrogels: Intrasite, Solosite

X

      

X

X

X

Requires cover dressing.

Change QD. Protect surroundings skin with Vaseline. Stays moist longer than saline dressings. Alternative for saline gauge packing.

Foam Island:.

Allevyn, Lyofoam

X

X

    

X

X

  

Soft cushion. Requires cover dressing.

Lyofoam helps control odor as dose MetroGel 0.75%

 

References for Pressure Ulcers:

  1. AMDA: Clinical Practice Guidelines, 1996.
  2. AMDA Pressure Ulcer Therapy Companion, 1999.
  3. Black, J.: Preventing Those Other Pressure Ulcers in Provider, December 2000, 24-25.
  4. Erwin-Toth, P., Hocevar, B.J.:Wound Care Selecting the Right Dressing in AJN, February 1995, 46-52.
  5. Maklebust, J., Sieggreen, M.: Pressure Ulcers, Guidelines for Prevention and Nursing Management, 2nd Edition, Springhouse Corporation, Springhouse, Pennsylvania, 1996.
  6. Reuben, D.B. et al: Pressure Ulcers in Geriatrics At Your Fingertips, 2000 Edition, 109-111.
  7. Sanders, S.: Meeting the Challenge of Pressure Ulcers in Advance for Nurse Practitioners, December 1996, 22-29.
  8. Spoelhof, GD: Management of Pressure Ulcers in the Nursing Home in Annals of Long-Term Care, Vol. 8, No. 8, August 2000, 69-77.
  9. Walker, D.: Choosing the Correct Wound Dressing in AJN, Vol. 96, No.9, September 1996, 35-39.

MS/4.01

ã EMS

 

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