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by Sharon DeMarco, CRNP
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:
- Pressure ulcer (Pr U) incidence is associated with an increased Morbidity & Mortality – nearly 70% die within six months. (Brown 2003)
- Pr U incidence is increasing in long term care. (LTC) (Horn et al. 2004)
- Reduction of pressure ulcer prevalence in LTC is a Healthy People 2010 initiative.
- Pr U incidence has been determined to be a quality of care indicator for LTC facilities and compliance is regulated by the Center for Medicare and Medicaid.(CMS 2004)
- Lawsuits due to Pr Us are on the rise. (Voss et al. 2005)
- Leg ulcers affect more individuals than Pr Us; one in four Americans over the age of 65 will develop a leg ulcer in their lifetime (Wound Ostomy and Continence Nurses Society [WOCN] 2002)
- Skin and wound allegations are the second leading cause of litigation in LTC. (Chizek 2003)
- Anatomy of normal skin
- What is a pressure ulcer?
- How do you prevent a pressure ulcer?
- What is NOT a pressure ulcer?
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.
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:
- Impaired mobility
- Chronic conditions
- Impaired sensation
- Decreased LOC
- Advance age
- Steroid use
- Pressure ulcer present
External contributing factors include:
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.
- Provide appropriate support surface
- Reposition every two hours in bed
- Off-load heels - use pillows or positioning boot
- Reposition every hour when in chair
- Use pillow between legs for side lying
- Do not position directly on trochanter
- Do not use doughnut-type devices
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:
- Use draw sheets for repositioning
- Encourage use of trapeze if possible
- Keep head of bed elevated ? 30? if tolerated
- Elevate foot of bed slightly, if condition permits
- Use pillow or wedge to support hip for 30? side-lying, lateral position
- Utilize lifts and transfer devices
- Rehabilitation or Restorative care if indicated
- Timely cleansing
- Apply barrier ointment to intact skin
- If skin is red or denuded use a paste
- Use appropriate incontinence disposables
- Apply fecal incontinence pouch if needed
Skin tears, denuded or excoriated skin, arterial ulcers, venous stasis ulcers and diabetic/neurotrophic ulcers are NOT pressure ulcers.
Skin Tear Prevention (Ayello 2003)
- Wash with gentle cleansing products
- Use emollients on skin
- Ensure adequate hydration/nutrition
- Transfer techniques to avoid friction/shear
- Support dangling extremities
- Avoid use of adhesive products on skin
Venous Ulcer Prevention (Vowden & Vowden 2006)
- Use of compression stockings (contraindicated if ABI < 0.5)
- Elevation of effected leg above level of the heart at rest
- Avoid use of products likely to be sensitizers (lanolin, fragrances)
- Avoid trauma to legs
- Calf muscle strengthening
- Regular follow up to monitor ABI
Prevention of Limb loss in Lower extremity arterial disease (Hopf et al. 2006)
- Consistent use of protective footwear
- Avoid friction, shear or trauma to feet/legs
- Apply emollients to keep skin pliable
- Avoid cold, caffeine, nicotine and constrictive garments
- Planned graduated walking program
- No use of thermal devices
- Routine professional foot care
Prevention of neuropathic ulcers (Steed et al. 2006)
- Control diabetes
- Daily care and inspection of feet
- Wear well-fitting protective footwear
- Avoid application of external heat
- Avoid use of OTC meds for corns/callous
- Avoid cold, caffeine, nicotine and constrictive garments
- Routine professional foot care
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.
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.
Documentation of location indicating which extremity, nearest bony prominence or anatomical landmark is necessary for appropriate monitoring of wounds. (Hess 2005)
Pressure ulcers are classified by stages as defined by the National Pressure Ulcer Advisory Panel (NPUAP). Originally there were four stages (I-IV) but in February 2007 these stages were revised and two more categories were added, deep tissue injury and unstageable.
Pressure Ulcer Staging
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.
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)
There are a number of classification and grading systems used in wound care but the simplest method uses the terms partial thickness or full thickness
• Partial thickness wound (PTW): damage to epidermis and/or dermis only
• Full thickness wound (FTW): damage to subcutaneous layer or deeper
- Length – from top edge to the bottom edge (head to toe) at longest point
- Width – from edge to edge perpendicular to the length at widest point
- Depth – straight in, perpendicular to the base, at deepest point
- Using the “clock concept” (12 o’clock is in the direction of the patient’s head and 6 o’clock is toward the feet)
- Where does it start and where does it end (clockwise direction)
- Tunnel depth is at it’s deepest point
- Location of deepest point
Assessing the appearance of tissue in the wound bed is critical for determining appropriate treatment strategies and to evaluate progress toward healing. (Keast et al. 2004)
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.
Slough - Soft, moist avascular tissue that adheres to the wound bed in strings or thick clumps; may be white, yellow, tan or green.
Granulation - Pink/red moist tissue comprised of new blood vessels, collagen fibers and fibroblasts. Typically the surface is shiny and moist with a granular appearance.
Epithelium - New pink and shin tissue/skin that grows in from the edges or as islands on the wound surface.
- None – base and dressing dry
- Slight – small amount in center of dressing
- Moderate – contained within the dressing
- Copious – extends beyond dressing onto clothing or bed linen
- Serous – thin, watery, clear or straw colored
- Serosanguineous – thin, pale red to pink
- Purulent – thick, opaque, tan, yellow to green and may have an offensive odor
- Consider treatment modality and frequency of dressing changes
Assess after cleansing (Garcia & Thomas 2006). Extreme malodor, especially if accompanied by purulent exudates is suggestive of infection. Most wounds do have an odor. The type of dressing can affect odor as well as hygiene and the presence of nonviable tissue (Keast et al. 2004).
- Describe wound edges (approximated, rolled, calloused)
- Describe periwound skin (indurated, erythematous, macerated, healthy)
- Describe presence of excoriation, denudement, erosion, papules, pustules or other lesions
Induration - Abnormal hardening of the tissue caused by consolidation of edema,
this may be a sign of underlying infection.
Erythema - Redness of surrounding tissue may be normal in the inflammatory stage of healing. However, if accompanied by an increase in temperature of tissue, exudates or pain may also be a sign of infection.
Maceration - Caused by excessive moisture, Tissue loses its pigmentation (appears lucid or turns white) and becomes soft and friable.
A critical aspect of local wound assessment both from the perspective of the patient and as a clinical indicator of infection. (Reddy, Keast, Fowler & Sibbald 2003) Include location, type/cause, rating (use validated scale), patient description and nonverbal signs.
Evaluation of infection
Infection – Signs and Symptoms:
- Redness, warmth and induration of adjacent tissues
- Pain or tenderness
- Dysmorphic and/or friable granulation
- Unusual odor
- Purulent exudates
- Systemic signs (fever, chills, sweats)
When to Culture: (Dow 2003)
- When signs of infection are present or when a clean wound fails to heal
- Always cleanse wound first
- Semi-quantitative swab collection is acceptable
- Quantitative biopsy is “gold standard” but expensive and invasive
- Edema –extent and persistence of pitting (1+ - 4+)
- Color changes - dependent rubor (purple-red discoloration) or elevation pallor (paling of the skin when leg raised to a 60° angle for 15 -60 seconds)
- Distal pulses –amplitude on palpation (0 – 4+)
- Neuropathy – skin changes (dryness, cracking), structural abnormalities, and loss of protective sensation (10gm monofilament exam – testing 10 points)
- Ankle-Brachial index – comparison of perfusion pressures
- Pulse volume recording - perfusion volume
- Doppler waveforms – single vessel flow
- Duplex imaging – ultrasound imaging for venous disease (also test for DVT)
- Transcutaneous oxygen pressure (TcPO2)
There are three phases of wound healing - inflammation, proliferation, maturation
- 0 – 3 days
- Hemostasis (bleeding stops)
- Inflammation (redness, swelling, warmth and pain maybe present)
- Phagocytosis (WBC’s engulf bacteria and foreign debris)
- Growth factor stimulation stimulation
- 3 – 21 days
- Angiogenesis (new blood vessels develop)
- Collagen synthesis (protein fibers)
- Granulation formation
- 21 days – 2 years
- Reorganization of collagen
- Tensile strength improves (up to 80% of original)
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)
- Manage comorbid conditions
- Adequate nutrition & hydration
- Remove nonviable tissue
- Maintain moisture balance
- Protect the wound and periwound skin
- Eliminate or minimize pain
- Prevent and manage infection
- Control odor
Manage comorbid condition
- Optimize cardiovascular and pulmonary functioning
- Support tissue oxygenation
- Maintain blood glucose control
Adequate nutrition & hydration (Harris & Frasier 2004)
- Encourage protein, calorie-dense foods and fluids, unless contraindicated
- Monitor intake, weight and skin turgor
- Assess and address impairments in dentition and swallowing
- Assist patients with meals if needed
- Dietary consult
Eliminate or Minimize Pain
- Address the cause (remove the source if external, treat the infection or medicate based on physiological stimulus)
- Pharmacological strategies –long acting drugs preferable, use breakthrough doses and prevent adverse effects
- Incorporate psycho-social, spiritual and culturally sensitive support
- Appropriate dressing selection, gentle removal and “Time out” during treatment administration
- Normal saline is the recommended solution
- Cavity wounds or tunnels may be irrigated
- Apply 4-15 (psi) pressure/force to remove debris without harming healthy tissue
Protect Wound and Periwound Skin
- Use barrier products to protect from adhesives and moisture
- Change dressings at appropriate intervals to avoid pooling of exudates
Prevent and Manage Infection
Critical colonization can result in failure to heal, poor quality tissue, increased friability and increased drainage (Frank, Bayoumi & Westendorp 2005). Determining whether the wound has a bacterial imbalance (critical colonization and infection) is of primary importance to healing (Sibbald, Woo & Ayello 2006).
- Superficial increased bacterial burden – topical agent with low toxicity, not likely to cause allergy and not associated with bacterial resistance
- Surrounding skin compartment infection – topical agent, swab culture and appropriate oral antibiotic agent (Sibbald 2003)
- Deep wound infection or osteomyelitis – parenteral antibiotics. Also consider tissue culture and additional lab tests (Frank et al. 2005)
Removal of Nonviable Tissue (Debridement)
Removes growth medium, controls/ prevents infection, defines extent of the wound and stimulates the healing process.
- Dry stable heel eschar
- Ischemic wounds with dry gangrene
- Coagulation disorders
Types of Debridement
- Autolytic debridement
- Lysis of necrotic tissue by the body’s white blood cells and enzymes.
- Leaves healthy tissue intact
- Naturally occurring physiological process that occurs in a moist environment
- Chemical Debridement - Accomplished by topical application of enzymes:
- Collagense (Santyl®)
- Papain with urea (Accuzyme®, Ethezyme®, Gladase®)
- Denaturing agents are also used: Sodium hypochlorite (Chlorpactin®, Dakin’s) Note: This is a nonselective method
- Mechanical Debridement
- Wet to dry dressing (not recommended as it is nonselective, causes repeated trauma to the wound bed and is frequently painful)
- Whirlpool (risk of cross contamination and contraindicated for some wounds such as venous stasis)
- Pulse lavage (requires skilled clinician, rigorous infection control precautions and may be cost prohibitive
- Sharp Debridement
- Conservative, sequential removal of avascular tissue, using sterile scalpel and mouse-tooth forceps
- Check for bleeding or clotting problems
- Pre-medicate if wound is painful
- Avoid local anesthetic
- Surgical Debridement
Maintain Moisture Balance (Rolstad & Ovington 2007)
- Dressings with a high moisture vapor transmission rate will allow moisture to escape and evaporate in minimally exudative wounds
- Moderate to heavily draining wounds require absorptive dressings
- Appropriate frequency of dressing changes
- Cleanse with each dressing change
- Debridement and antimicrobials as indicated
- Charcoal dressings
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:
- Recently closed wound, Stage I pressure ulcer, denuded or excoriated skin - Encourage adequate perfusion and protect from further tissue damage.
- Stage II or PTW - Encourage regeneration of tissue and protect wound surface.
- Stage III/IV - Promote granulation and contraction (epithelialization)
- Symptom management: elimination or reduction of pain, control of odor and exudates, treatment/prevention of infection
- Quality of life objectives: restoration of some sense of control, maintenance of function and independence, control of caregiver burden, reduction of distress for patient and family.
- Wound history
- Comorbid conditions
- Patient/caregiver needs
Etiology - The cause of the wound directly affects dressing choices. For example:
- Arterial ulcers generally require moisture
- Neuropathic wounds often have tunnels which require packing strips
- Pressure ulcers often have undermining which requires packing to fill dead space
- Venous insufficiency requires compression and exudate management
- Duration and course of wound healing
- Previous dressings/treatment strategies
- Health care providers consulted for wound
- Success/challenges of previous treatment
- Diabetes – impairs wound healing, compromises perfusion and there is an increased risk of infection.
- Mixed (arterial and venous disease) or CHF - compression may be contraindicated
- Obesity – increased risk of venous hypertension, infection and dehiscence (Wilson & Clark 2003)
- Immunosupression – increases risk of infection and impairs healing
- Size and extent of tissue loss determines both the dressing size and material
- Wound packing needed for larger wounds
- Exposed tendons/ligaments require moisture and protection
- Clean healthy granulation – keep moist
- Slough – debridement: If slight amount, keep moist to encourage autolysis, If there is a moderate amount, use a chemical or mechanical agent. For large amounts, perform serial sharp debridement and may also use adjunct treatment with chemical or mechanical agent.
- Epithelium- moist protective dressing
- The volume and type of exudates are significant determinants in selection of primary and secondary dressings
- Adequate containment of exudate is critical to manage increased bioburden , protect the periwound skin, control odor and avoid overuse of wound care products (Rolstadt & Ovington 2007)
- Commonly associated with an infected wound
- Fungating lesions or wounds with high colonization due to necrotic debris may be malodorous
- Odor may cause considerable patient/ caregiver stress and embarrassment
Perimeter - Condition of the periwound skin influences the type of products used and may indicate the need for additional products.
- Barriers are indicated for fragile or compromised skin
- Maceration indicates need for exudate management
- Topical treatment may be required for fungal infections
- Who is providing the care?
- Do they have cognitive, dexterity or visual impairments to consider?
- In what setting will the dressings be done?
- Are education and/or training needed?
- Are health care resources available?
- Is the treatment plan congruent with the culture/beliefs of the patient/caregiver?
- Does the patient have access to supplies and services?
- Are there financial constraints or limitations with insurance coverage?
- Is transportation a factor in accessing care or supplies?
- Bacitracin®, - Broad spectrum, low cost, apply daily.
- Bactroban®) - Excellent penetration, effective for MRS. Apply three times daily.
- Cadexomer Iodine (Iodosorb®) – Contains microspheres that absorb bacteria while slowly releasing iodine and is less toxic to granulation. Broad spectrum, including virus and fungus. Effective for up to 72 hours.
- Nanocrystalline silver (Acticoat 7®) – Releases bactericidal concentrations up to 7 days. Use sterile water, not saline. May stain skin. May be cost prohitive.
- Polysporin® powder – For Gram-negative and Gram positive organisms and Pseudomonas. May use with Santyl®. Apply daily.
- Silver sulfadiazine (Silvadene®) cream – Broad spectrum. Cost effective, but requires prescription. Avoid in sulfa allergy. Apply daily.
- Silver impregnated hydrofiber (Aquacel Ag®) – Highly absorbent. Silver stays in dressing, very little is deposited into wound base. Change when saturated
- Silver gel (SilvaSorb®) – Broad-spectrum and low toxicity. Delivers time-released silver for 3 days.
- Sodium hypochlorite (Chlorpactin®) – Most appropriate for malodorous wounds with large amounts of slough. Twice daily for short term treatment only (less than 10 days).
- Derived from seaweed
- Highly absorbent and biodegradable
- Hemostatic properties
- Conforms to wound shape
- Maintains moist environment
- Virtually painless removal
- Examples - Calginate®, Algisite®
Barriers - Primary function - protection
- Clear liquid – Skin Prep®, No Sting®
- Petrolatum based – Vaseline®, A&D®
- Pastes – Criticaid®, Sensicare®
- Powders – Stomahesive®, Karaya®
- Solids - Stomahesive® wafer, Eakin® seal
- Activated charcoal dressings adsorb volatile odors and bacteria
- Also available with silver which enhances bactericidal properties
- Examples - Clinisorb®, Actisorb®
Collagen – to stimulate wound repair and epithelial activity
- Mild absorptive capacity
- Usually derived from bovine source (check for patient sensitivity)
- Examples - Fibracol®, Profore®
Most have three layers: a semi-adherent or non-adherent layer to protect the wound bed, an absorbent layer and a moisture vapor permeable layer with an adhesive border.
Examples – Covaderm Plus®, Alldress®, CovRsite®
- Applied by trained professionals to reduce edema by increasing venous return
- Available as two, three or four layers
- Degree of tension used in application is critical to effectiveness
- Contraindicated in severe LEAD and CHF
- Examples – Coban®, Coflex®, Profore®
- Made from hydrophilic polyurethane
- Highly absorbent
- Decreases maceration of periwound tissue
- May be used as primary dressing for treatment of hypergranulation
- Examples- Biatain®, Allevyn®, Polyderm®
- Material may include cotton, rayon and/or polyester
- Available in rolls, strips or squares
- Adheres to wound tissue
- May lint or shred if cut
- Contain carboxymethylcellulose (CMC) combined with pectin
- Mildly absorbent
- Maintains moist wound surface
- May have an acrid odor when removed
- Not recommended for ischemic wounds (due to occlusive properties)
- Examples – Duoderm®, Tegasorb®
- Composed of highly absorbent CMC
- Absorbs twice as much as alginates
- Exudate is bound in the center of the fiber and is not bioresorbable
- Require secondary dressing
- Example - Aquacel®
- Consists of a three dimensional cross-linked structure made up of hydrophilic polymers
- Increases moisture content
- Produces soothing effect
- Available as amorphous gel and sheets
- Examples – Intrasite®, Vigilon®
NaCl impregnated dressings
- For moderate to high exudates
- Hypertonic medium discourages bacterial proliferation
- Promotes mechanical and autolytic debridement
- Available in sheets or ribbon (for tunnels)
- Examples - Mesalt®, Curasalt®
Negative pressure wound therapy - Use of sub-atmospheric pressure to promote contraction, remove excess exudates, reduce edema and increase blood flow
- Indicated for deep chronic open wounds, dehisced surgical sites, pressure ulcers, mesh grafts and tissue flaps
- Requires trained clinician and is costly
- Example – V. A. C. system
Petrolatum impregnated dressings
- For minimal exudates
- Protects wound base and perimeter
- Provides moist environment to promote epithelialization
- Requires secondary dressing
- Examples – Vaseline gauze®, Adaptic®
- Consists of polyurethane or synthetic polymer sheets
- Indicated for absent or minimal exudates
- May be used to promote autolysis
- Often used as a secondary dressing
- Examples - Tegaderm®, Opsite®
|None to moderate exudates||Gauze with tape or composite|
|Moderate to heavy exudates||Foam with tape or composite|
|Frequent soiling 2? incontinence||Hydrocolloid, film or composite|
|Fragile skin||Hydrocolloid, film or composite|
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