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:
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.
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:
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)
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.
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)
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.
Induration - Abnormal hardening of the tissue caused by consolidation of edema,
Evaluation of infection
When to Culture: (Dow 2003)
There are three phases of wound healing - inflammation, proliferation, maturation
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 condition
Adequate nutrition & hydration (Harris & Frasier 2004)
Eliminate or Minimize Pain
Protect Wound and Periwound Skin
Removal of Nonviable Tissue (Debridement)
Types of Debridement
Maintain Moisture Balance (Rolstad & Ovington 2007)
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:
Etiology - The cause of the wound directly affects dressing choices. For example:
Perimeter - Condition of the periwound skin influences the type of products used and may indicate the need for additional products.
Barriers - Primary function - protection
Collagen – to stimulate wound repair and epithelial activity
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
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.