by Sharon DeMarco, CRNP Show
Introduction Education of patients, families, caregivers and healthcare providers is the key to a proactive program of prevention and timely, appropriate interventions (Erwin-Toth and Stenger 2001). Wound management involves a comprehensive care plan with consideration of all factors contributing to and affecting the wound and the patient. No single discipline can meet all the needs of a patient with a wound. The best outcomes are generated by dedicated, well educated personnel from multiple disciplines working together for the common goal of holistic patient care (Gottrup, Nix & Bryant 2007). Significance of the problem:
Prevention
Age related skin changes (see comparison figures below-normal on the left, aging on the right) include thinning and atrophy of epithelial and fatty layers. Additionally, collagen and elastin shrink and degenerate, and dermal fibroblasts cease replicating, all resulting in thinner, drier and less elastic skin that heals more slowly. (top of section)
Previously called decubitus or bed sore, a pressure ulcer is the result of damage caused by pressure over time causing an ischemia of underlying structures. Bony prominences are the most common sites and causes. There are many risk factors that contribute to the development of pressure ulcers. CMS (2004) recommends patients in LTC be assessed for risk on admission, weekly for the first four weeks then reassessed quarterly. There are many contributing factors. Intrinsic contributing factors include:
External contributing factors include:
(top of section) How Do You Prevent a Pressure Ulcer? (WOCN 2003; AHCPR 1992) Proper skin care is crucial and involves inspecting skin daily and an individualized bathing schedule, using warm (not hot) water and mild soap. Avoid massage over bony prominences and use lubricants if skin is dry. Managing pressure is also necessary and the following is recommended.
Friction and shear need to be reduced. Friction is the mechanical force exerted when skin is dragged against a coarse surface while shear is the mechanical force caused by the interplay of gravity and friction. It exerts a force parallel to the skin resulting in angulation and stretching of blood vessels (shown below on right) within the sub-dermal tissues, causing thrombosis and cellular death. This manifests as necrosis and undermining of the deepest layers (Pieper 2007). To reduce friction and shear, the following is recommended:
Manage Incontinence
What is Not a Pressure Ulcer? Skin tears, denuded or excoriated skin, arterial ulcers, venous stasis ulcers and diabetic/neurotrophic ulcers are NOT pressure ulcers. Skin Tear Prevention (Ayello 2003)
Venous Ulcer Prevention (Vowden & Vowden 2006)
Prevention of Limb loss in Lower extremity arterial disease (Hopf et al. 2006)
Prevention of neuropathic ulcers (Steed et al. 2006)
(top of section) Assessment (Nix 2007)
Holistic assessment of a patient with a wound includes systemic factors, psychosocial factors, and local factors. Systemic factors assess etiology, duration, and decreased oxygenation or perfusion of the wound as well as comorbid conditions, medications, and host infection of the patient. Psychosocial factors to address in a holistic assessment include the patient’s knowledge deficits, cultural beliefs and financial constraints including a lack of or insufficient health insurance. Additionally, it is necessary to assess whether the patient has impaired access to appropriate resources and any social support – family, significant others or community resources. Local factors to assess include desiccation, excess exudates, low wound temperature, recurrent trauma (also friction & pressure), infection, and necrosis and foreign bodies. Wound Assessment An assessment of the wound should be done weekly and be used to drive treatment decisions. Wound assessment includes: location, class/stage, size, base tissues, exudates, odor, edge/perimeter, pain and an evaluation for infection. Location Class/Stage Pressure Ulcer Staging Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Stage III - Full thickness skin loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining/tunneling. Stage IV - Full thickness skin 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. 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. (Suspected 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. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. (NPUAP 2/07) Class Size
Base Tissues Necrosis/Eschar - Black, brown or tan devitalized tissue that adheres to the wound bed or edges and may be firmer or softer than the surrounding skin. Exudates
Type
Odor Edge/Perimeter
Induration - Abnormal hardening of the tissue caused by consolidation of edema, Pain Evaluation of infection
When to Culture: (Dow 2003)
(top of section) Additional Assessment for Lower Extremity Wounds (WOCN 2002) Physical Exam
Diagnostic Tests
(top of section) Wound Healing
Phases of Wound Healing There are three phases of wound healing - inflammation, proliferation, maturation Inflammatory Phase
Proliferation Phase
Maturation Phase
The healing process varies depending on the stage of the pressure ulcer. Stage I & II pressure ulcers and partial thickness wounds heal by tissue regeneration. Stage III & IV pressure ulcers and full thickness wounds heal by scar formation and contraction. Data indicate a 20% reduction in wound size over two weeks is a reliable predictive indicator of healing. (Flanagan 2003) (top of section) Optimization of Wound Environment
Manage comorbid condition
Adequate nutrition & hydration (Harris & Frasier 2004)
Eliminate or Minimize Pain
Cleanse
Protect Wound and Periwound Skin
Removal of Nonviable Tissue (Debridement) Contraindications
Types of Debridement
Maintain Moisture Balance (Rolstad & Ovington 2007)
Control Odor
(top of section) Treatment
The provider’s role is to assist in the development of a sustainable plan designed to help achieve mutually agreed upon goals. (Nix & Pierce 2007) Treatment goals should be identified and can be curative or palliative. Palliative care objectives focus on symptom management and quality of life. The objectives vary depending on the staging of the wound:
Palliative Wound Care (Bradley 2004)
(top of section) Factors for Dressing Selection
Etiology - The cause of the wound directly affects dressing choices. For example:
Wound History
Comorbid conditions
Size
Base
Exudates
Odor
Perimeter - Condition of the periwound skin influences the type of products used and may indicate the need for additional products.
Patient/caregiver needs
Access
Product Categories (Sibbald 2003) (Okan et al. 2007) (Nix 2007) Antimicrobials (topical)
Alginates
Barriers - Primary function - protection
Collagen – to stimulate wound repair and epithelial activity
Composite products Compression wraps
Foams
Gauze
Hydrocolloids
Hydrofiber
Hydrogels
NaCl impregnated dressings
Negative pressure wound therapy - Use of sub-atmospheric pressure to promote contraction, remove excess exudates, reduce edema and increase blood flow
Petrolatum impregnated dressings
Transparent Films
Cover Dressings (top of section) References Agency for Health Care Policy and Research [AHCPR] (1992). Pressure Ulcers in Adults: Prediction and Prevention - Clinical Practice Guideline No. 3. Rockville, MD: U. S. Department of Health and Human Services. Ayello, E. A. (2003). Preventing pressure ulcers and skin tears. Retrieved 4/13/2007, from http://www.guidelines.gov/summary/summary.aspx?doc_id=3511 Bradley, M. (2004, July). When healing is not an option: Palliative care as a primary treatment goal. Advance for Nurse Practitioner., 50-57. Brown, G. (2003). Long-term outcomes of full-thickness pressure ulcers: Healing and mortality. Ostomy Wound Management, 49(10), 42-50. Chizek, M. (2003, March 17). Wound care & lawsuits., Advance for Nurses (MD/DC/VA), 31-32. Department of Health & Human Services (2004). Centers for Medicare & Medicaid Services (CMS) Manual System [Pub. 100-07] State Operations Certification. Baltimore, MD: Centers for Medicare & Medicaid Services. Dow, G. (2003). Bacterial swabs and the chronic wound: When, how, and what do they mean? Ostomy/Wound Management, 49(5A[suppl]), 8-13. Erwin-Toth, P., & Stenger, B. (2001) Teaching wound care to patients, families and healthcare providers. In D. L. Krasner, G. T. Rodeheaver & R. G. Sibbald (Eds.), Chronic wound care: A clinical source book for healthcare professionals (3rd ed., pp. 35-41). Wayne, PA: HMP Communications. Flanagan, M. (2003). Improving accuracy of wound measurement in clinical practice. Ostomy/Wound Management, 49(10), 28-40. Frank, C., Bayoumi, I., & Westendorp, C. (2005). Approach to infected skin ulcers. Canadian Family Physician, 51, 1352-1359. Garcia, A. D., & Thomas, D. R. (2006). Assessment and management of chronic pressure ulcers in the elderly. The Medical Clinics of North America, 90, 924-944. Gottrup, F., Nix, D. P. & Bryant, R. A. The multidisciplinary team approach to wound management. In R. A. Bryant, & D. P. Nix (Eds.), Acute & chronic wounds: Current management concepts (3rd ed., pp. 23-38). St. Louis, MO: Mosby. Harris, C. L., & Fraser, C. (2004). Malnutrition in the institutionalized elderly: The effects on wound healing. Ostomy and Wound Management, 50(10), 54-63. Hess, C. T. (2005). The art of skin and wound care documentation. Home Healthcare Nurse, 23(8), 502-512. Hopf, H. W., Ueno, C., Aslam, R., Burnand, K., Fife, C., & Grant, L. et al. (2006). Guidelines for treatment of arterial insufficiency ulcers. Wound Repair and Regeneration, 14, 693-710. Horn, S. D., Bender, S. A., Ferguson, M. L., Smout, R. J., Bergstrom, N., & Taler, G. et al. (2004). The national pressure ulcer long-term care study: Pressure ulcer development in long-term care residents. Journal of the American Geriatric Society, 52(3), 359-367. Keast, D. H., Bowering, K., Evans, A.W., Mackean, G. L., Burrows, C., & D’Souza, L. (2004) MEASURE: A proposed assessment ramework for developing best practice recommendations for wound assessment. Wound Repair and Regeneration, 12(3), S1-17. National Pressure Ulce Advisory Panel (NPUAP) (2007, February). Pressure ulcer definition and stages. Retrieved 4/13/2007, from http://www.npuap.org Nix, D. P. (2007). Patient assessment and evaluation of healing. In R. A. Bryant, & D. P. Nix (Eds.), Acute & chronic wounds: Current management concepts (3rd ed., pp. 130-148). St. Louis, MO: Mosby. Nix, D. P., & Peirce, B. (2007). Facilitating adaptation. In R. A. Bryant, & D. P. Nix (Eds.), Acute & chronic wounds: Current management concepts (3rd ed., pp. 566-578). St. Louis, MO: Mosby. Okan, D., Woo, K., Ayello, E. A., & Sibbald, R. G. (2007). The role of moisture balance Pieper, P. (2007). Mechanical forces: Pressure, shear and friction. In R. A. Bryant, & D. A. Nix (Eds.), Acute & chronic wounds: Current management concepts (3rd ed., pp. 205-234). St. Louis, MO: Mosby. Reddy, M., Keast, D., Fowler, E., & Sibbald, G. (2003). Pain in pressure ulcers. Ostomy and Wound Management, 49(4A [suppl]), 30-35. Reddy, M., Kohr, R., Queen, D., Keast, D., & Sibbald, R. G. (2003,). Practical treatment of wound pain and trauma: A patient-centered approach. An overview. Ostomy and Wound Management, 49(4A (Suppl)), 2-15. Rolstad, B. S., & Ovington, L. G. (2007). Principles of wound management. In R. A. Bryant, & D. A. Nix (Eds.), Acute & chronic wounds: Current management concepts (3rd ed., pp. 391-426). St. Louis, MO: Mosby. Sibbald, R. G. (2003). Topical antimicrobials. Ostomy and Wound Management, 49(5A[suppl]), 14-18. Sibbald, R. G., Woo, K., & Ayello, E. A. (2006). Increased bacterial burden and infection: The story of NERDS and STONES. Advances in Skin & Wound Care, 19, 447-461. (top of page) What is the best dressing for pressure ulcer?alginate dressings – these are made from seaweed and contain sodium and calcium, which are known to speed up the healing process. hydrocolloid dressings – contain a gel that encourages the growth of new skin cells in the ulcer, while keeping the surrounding healthy skin dry.
What type of dressing is used on a Stage 1 pressure ulcer?Thin hydrocolloid dressings (eg DuoDERM® SignalTM and DuoDERM® Extra Thin) are increasingly used in the management of Category/Stage I pressure ulcers. The slippery outer surface assists in reducing friction or shear to the underlying skin to protect it against further damage7.
Which type of dressing is used for a stage 3 pressure ulcer?Alginate dressings, which have many of the same properties as foam, are another choice for Stage III pressure ulcers. Both dressing types maintain a moist wound environment and may be used for tunneling and undermining.
What is the best dressing to promote wound healing?Collagen
Collagen dressings encourage the wound healing process in a range of ways; these include by helping to remove dead tissue, aiding the growth of new blood vessels, and helping to bring the wound edges together, effectively speeding up healing.
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