- Email: [email protected]
Pressure Ulcer Update for Primary Care
Pressure Ulcer Update for Primary Care Carole Bauer, MSN, ANP-BC
ABSTRACT Many consider pressure ulcers a problem only for long-term care or acute care.Yet many people are admitted to the acute care setting with a pressure ulcer that has occurred while they are residing at home. For the nurse practitioner in primary care, recognizing the alterable causes of a pressure ulcer and implementing corrective action may prevent the development of a pressure ulcer or halt the progression of a pressure ulcer before a patient requires complex management, including debridement and possible hospitalization. Keywords: decubitus ulcer, pressure ulcer, pressure ulcer prevention, pressure ulcer treatment, wounds © 2012 American College of Nurse Practitioners
I
n 2008, the Agency for Healthcare Utilization and Quality (AHRQ) reported on the 2006 results of the Healthcare Cost and Utilization Project (HCUP) as it related to hospitalizations for pressure ulcers. This document reports an 80% increase in hospitalizations where a pressure ulcer was noted as either a primary or secondary diagnosis for the admission, compared to data from 1993. The majority of patient admissions for which a pressure ulcer was noted were for a primary diagnosis other than pressure ulcer.1 Based on these data, a clinician can conclude that the number of patients living with such an ulcer is rising. Many patients are admitted to hospitals with pre-existing pressure ulcers or are being discharged to primary care with one. Primary care nurse practitioners (NPs) see patients across the lifespan and the spectrum of care. It is important to be aware of changes that may occur as a result of aging or progressive illness that increase the likelihood that a patient may develop a pressure ulcer in any setting, including the outpatient setting. Mrs. Johnson is one such www.npjournal.org
example of a patient who has developed a pressure ulcer in an outpatient setting. She is a 76-year-old woman with a history of breast cancer, hypertension, asthma, and diabetes. She has recently completed a 6-month course of chemotherapy and has had a progressive weight loss over the past 6 months. She presents in the primary care clinic for a 3-month appointment related to her hypertension, asthma, and diabetes. She normally arrives at her appointments independently, but today she is accompanied by her daughter and is sitting in a wheelchair. She and her daughter report that she has had a decreased appetite over the past 6 months, at times eating less than half of her regular meals. They also report that although she has completed her chemotherapy, she has not yet regained her strength. She is spending a good deal of time at home sitting in a chair. They report that the patient has a sore on her “tailbone.” In addition to her normal care for her hypertension and diabetes, Mrs. Johnson and her daughter are looking for help with the management of this sore. The Journal for Nurse Practitioners - JNP
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Figure 1. Pressure Ulcer Stages
Figure 1A. Stage I: Unblanchable erythema.
Figure 1B. Stage II: Partial thickness skin loss.
Figure 1C. Stage III: Full thickness skin loss.
Figure 1D. Stage IV: Full thickness skin loss with involved supporting structure.
Figure 1E. Suspected deep tissue injury. Purple or maroon
Figure 1F. Unstageable. Full depth is unknown as ulcer base
tissue in a localized area of intact skin.
is not visible.
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A pressure ulcer is defined by the National Pressure Ulcer Advisory Panel (NPUAP) as “…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. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors has yet to be elucidated.”2 (p. 16) Pressure ulcers have an exclusive classification system, defined by the NPUAP as stages I-IV, suspected deep tissue injury, and unstageable (Figure 1). A stage I pressure ulcer, defined as nonblanchable erythema, is intact skin with an area of localized redness that does not blanch and is usually located over a bony prominence. A stage I ulcer may be difficult to determine in dark-skinned individuals. A stage II pressure ulcer is a partial-thickness ulceration. It can present as a shallow, open ulcer. The base of the ulcer is pink, and there is no slough tissue present in the wound bed. It may also present as a serumfilled blister. Bruising will not be present. A stage III ulcer is full-thickness skin loss. Subcutaneous tissue may be visible in the wound bed. Slough may be present, but it does not prevent the clinician from seeing the full depth of tissue destruction. Depending on the location of the ulceration and the underlying structures, the depth of a stage III ulcer may vary. Stage IV ulcers are also full-thickness ulcers, but there is also exposed bone, tendon, or muscle noted in the wound bed. Slough or eschar may also be present in this stage. An unstageable pressure ulcer has an unknown full depth of ulceration from the presence of slough or eschar. Until the slough or eschar is removed to expose the base of the wound bed, an ulcer with these characteristics cannot be staged. The final stage of pressure ulceration is suspected deep tissue injury. This is purple or maroon tissue in a localized area of intact skin. This stage of ulceration may also be a blood-filled blister and may rapidly expose additional layers of tissue destruction, even with optimum treatment.2 The major cause of pressure ulcers is pressure, but several other factors play a key role in determining at what level of pressure a patient will develop an ulcer. The intensity and duration of the pressure, as well as tissue tolerance, are key determinants in ulcer development. There is an inverse relationship between duration www.npjournal.org
and intensity in ischemia development, which results in pressure ulcer development. Long periods of low intensity pressure result in ulceration, just as high intensity pressure over a short period will also result in ulceration. Tissue tolerance refers to the “…integrity of the skin and supporting structures that influence the skin’s ability to redistribute the applied pressure.”3 (p. 128) Both intrinsic and extrinsic factors affect tissue tolerance and include shear, friction, moisture, nutritional debilitation, advanced age, low blood pressure, stress, smoking, elevated body temperature, and other miscellaneous factors that impair blood flow.3 Each of these factors can be assessed by a structured risk-assessment scale. According to the NPUAP, each health care setting should have a policy that recommends evaluating patients for their risk of pressure ulcer development. For Mrs. Johnson, several confounding issues may have led to the development of her pressure ulcer. Assessment for risk in the primary care setting may help to prevent patients from developing pressure ulcers at home. As Mrs. Johnson is evaluated in the primary care clinic, a structured risk assessment should include the following parameters, documented in the NPUAP guidelines for pressure ulcer prevention and treatment: 1. Activity and mobility: Individuals who are bedfast or chairfast should be considered at risk for pressure ulcer development. 2. Skin condition: Any patient with an alteration to intact skin should be considered at risk for pressure ulcer development. 3. Physical condition: Several factors have been determined to increase a patient’s risk to develop a pressure ulcer: a. Nutritional indicators, such as hemoglobin, anemia, serum albumin levels, and weight b. Factors affecting perfusion and oxygenation, such as diabetes, cardiovascular instability, low blood pressure, and oxygen use c. Fecal and urinary incontinence and general skin moisture d. Advancing age e. Friction and shear. Generally, as mobility and activity decrease, friction and shear increase.2 The assessment of Mrs. Johnson’s wound should include a history of the wound and the treatment that she and her daughter have been doing at home. Key The Journal for Nurse Practitioners - JNP
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components of this assessment will include how long she has had the wound. Has she noticed anything making the wound worse or better? Has she had a wound in this location in the past? If so, what treatment did she use to heal it? What is their current treatment? Are they washing it with anything in particular? Is there a dressing in place? Are they using any home remedies on the wound? Frequently, patients and families will have home remedies that, in fact, make a wound worse rather than better. These home remedies can include cleaning the wound with alcohol, peroxide, and betadine, which are known toxins to granulocytes and will not promote healing. A second common factor to explore during the patient interview is to determine where the patient is sleeping and what equipment in the home the patient is using. Many patients with respiratory issues sleep in reclining chairs at home and are unable to reposition themselves during sleep. Home medical equipment, such as bedside commodes, shower chairs, and other lifting devices, can contribute to friction and shear and thus increase the incidence of pressure ulcer formation. Is physical or occupational therapy indicated? During Mrs. Johnson’s interview, the clinician determines that she is not only spending long periods in a wheelchair during the day, but she is also sleeping in a recliner at home at night. She has never had a wound in this location before, but it has been present for 30 days. She and her daughter have been cleaning the wound with hydrogen peroxide and placing a bandage with over-the-counter triple antibiotic ointment on it when the patient bathes every other day. On assessment, Mrs. Johnson has developed a stage II pressure ulcer (partial thickness skin loss) and thus requires interventions to relieve the cause of the ulcer and correct underlying systemic conditions that may have contributed to its development, as well as appropriate topical therapy. Mrs. Johnson’s assessment reveals that she has several factors that place her at risk for pressure ulcer development. She is now chairfast for much of the day and requires a seating surface that is able to redistribute the pressure when she is in it. Additionally, she should be on a sleep surface that also redistributes the pressure. A sleep surface is necessary because of lessening tissue tolerance from repeated exposure to pressure. Support surfaces for both the chair and the bed are available 732
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from durable medical equipment companies and should be a medical-grade surface. Suppliers who participate with Medicare can be located at www.medicare.gov/ Supplier. These vendors can help determine the appropriate support surface for the patient at risk for a pressure ulcer or who has already developed one. The choice of a support surface should be individualized to meet the patient’s needs. Support surfaces are categorized as either reactive or active surfaces. A reactive support surface is “a powered or nonpowered support surface with the capability to change its load distribution properties only in response to applied load.”2 (p. 129) An active support surface is “a powered support surface with the capability to change its load distribution properties, with or without applied load.”2 (p. 129) Reactive support surfaces are appropriate for pressure ulcer prevention in combination with a turning schedule. This type of support surface, with few exceptions, is appropriate in the home setting.4 Examples of reactive surfaces include those filled with gel, foam, air, or a combination of foam and air. In 2008, Norton, Coutts, and Sibbald developed the Support Surface Selection Tool, a decision tree to help clinicians determine which support surface would be appropriate. This decision tree has since been expanded to include an algorithm that takes into consideration patient-specific criteria and features of the support surface classification chosen (ie, active or reactive). This decision tree can be useful in guiding the primary care provider to specify features that may help prevent pressure ulcers.5 The Centers for Medicare and Medicaid Services (CMS) define support surfaces into 3 groups to guide reimbursement. Beneficiaries must meet specific criteria for a surface to be eligible for reimbursement. Groups 1 and 2 surfaces are designed to replace existing mattress systems, while Group 3 is a complete bed system. CMS policy defines down the groups as follows: • Group 1—A group 1 support surface is covered if the patient is completely immobile. Otherwise, he or she must be partially immobile or have any stage pressure ulcer and demonstrate 1 of the following conditions: impaired nutritional status, incontinence, altered sensory perception, or compromised circulatory status. A physician order must be obtained prior to delivery of the equipment and should be kept on file by the supplier. Volume 8, Issue 9, October 2012
• Group 2—A group 2 support surface is covered if the patient has a stage II pressure sore located on the trunk or pelvis, has been on a comprehensive pressure sore treatment program (which has included an appropriate group 1 support surface for at least 1 month), and has sores which have worsened or remained the same over the past month. A group 2 support surface is also covered if the patient has large or multiple stage III or IV pressure sores on the trunk or pelvis, or if he or she has had a recent mycutaneous flap or skin graft for a pressure sore on the trunk or pelvis and has been on a group 2 or 3 support surface. • Group 3—A group 3 support surface is covered if the patient has a stage III or IV pressure ulcer, is bedridden or chair-bound, would be institutionalized without the use of the group 3 support surface, is under the close supervision of the patient’s treating physician, at least 1 month of conservative treatment has been administered (including the use of a group 2 support surface), a caregiver is available and willing to assist with patient care, and all other alternative equipment has been considered and ruled out.6 (p. 4) Based on Mrs. Johnson’s score on the support surface selection tool, a hospital bed with a non-powered air and foam-filled surface was chosen for her bed surface. Mrs. Johnson has reported that she spends a long time sitting in her wheelchair, thus a pressure redistribution surface for her wheelchair is also indicated. Ideally, she should be evaluated in a seating clinic by a team of providers whereby both her wheelchair and an appropriate cushion are evaluated and selected based on her size. Seating clinics are available in a variety of settings, including rehabilitation centers, physical therapy centers, and durable medical equipment providers. Mrs. Johnson’s history of poor appetite makes nutritional screening and counseling another component that is important in the assessment of her pressure ulcer. Nutritional assessment can be accomplished using standardized tools, such as the Mini Nutritional Assessment (available at www.mna-elderly.com) or Nutritional Screening Initiative tool (available at www.cdaaa.org/images/Nutritional_Checklist.pdf). Annual nutrition screening as part of a complete history and physical exam can help to identify social and environmental factors that may be alterable. Supportive nutritional therapy is a balance between energy and protein requirements and depends on many variables, such as disease status and presence and severity of a wound. A healthy person requires approxiwww.npjournal.org
mately 0.8 g of protein per kg per 24 hours and 20–35 calories/kg of body weight/24 hours,7 but according to the NPUAP, a patient at risk requires a minimum of 30–35 kcal per kg body weight per day with 1.25–1.5 g/kg/day protein and 1 ml of fluid intake per kcal per day. To achieve this goal, the NPUAP recommends offering high protein mixed oral supplements in addition to the usual diet. These supplements should be offered between meals to avoid interfering with normal food intake.2 If Mrs. Johnson were having issues with moisture, such as urinary or fecal incontinence, several basic interventions can be instituted in the primary care setting. Timed voiding, where the patient goes to the toilet on a schedule rather than on the urge to void or defecate, is a strategy that may help to decrease incontinent episodes. The patient and family can also be counseled to assess the physical environment. An assessment of the physical environment may reveal barriers to the toilet. Alleviating these physical barriers may decrease incontinent episodes. Another basic intervention includes skin protection with a barrier cream (eg, dimethicone or a zinc-based cream). At times, the use of an incontinence brief may be indicated. There are several different levels of absorption and multiple different types of products available to manage incontinence. Patients should be referred to a DME provider or Internet source (eg, National Association for Continence www.nafc.org) for resources to manage incontinence. The actual exam of Mrs. Johnson’s ulcer is the next component of her care. Assessment criteria of any wound should include location, extent of tissue loss (full thickness or partial thickness), size (length, width, and depth), a description of the character of the wound bed, and amount and type of exudate. Mrs. Johnson’s wound is located on her coccyx. It has partial thickness skin loss, so therefore it is shallow. It measures 1 cm long × 2 cm wide. The periwound skin is intact without signs of maceration. There is minimal drainage. The wound bed is 100% pink tissue. This would be characterized as a stage II pressure ulcer. The next step is to choose topical therapy for the wound. The first step in the dressing process is cleansing and irrigation. Wounds should be cleansed with each dressing change. Normal saline irrigations with a force of 4 to 15 psi are appropriate to remove surface bacteria while not inoculating the underlying tissue. The Journal for Nurse Practitioners - JNP
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Figure 2. Dressing Choice Algorithm
Key Assumptions : • Wound IS NOT infected • Wound DOES NOT require debridement
No Exudate: hydrogel, film, composite Minimal Exudate: film, composite, thin hydrocolloid, thin foam,
Shallow
Moderate Exudate: hydrocolloid, foam, alginate, hydrofiber Heavy Exudate: alginate, hydrofiber, superabsorbant, pouch
Depth of the Wound
No Exudate: hydrogel, hydrating impregnated Gauze (both require a cover dressing) Minimal Exudate: hydrating impregnated gauze, collagen, hydrogel, wound fillers (Cover dressing required)
Deep
Moderate Exudate: alginate, foam cavity dressing, absorbent impregnated gauze, collagen, superabsorbent, hydrofiber (cover dressing required) Heavy Exudate: alginate, foam cavity dressing, hydrofiber, superabsorbent, (cover dressing required) pouch
This can be done with a 19-gauge angiocatheter and a 35-ml syringe.8 Prepackaged canisters of pressurized saline are available and are good choices for patients at home. After cleansing the wound bed, a topical dressing should be applied. The type of dressing will depend on the wound bed characteristics. Amount and type of exudate, wound depth, tunneling and undermining, type of tissue present in the wound bed, and the condition of the periwound skin all play a role in determining the best dressing. There are many categories of wound dressings and many dressings in each category. Using an algorithm can make dressing selection easier (Figure 2). It is wise to become familiar with 1 dressing in each category to streamline the ordering process (Table 1). 734
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Mrs. Johnson’s wound is shallow with minimal exudate. Her wound could be managed using either a composite, thin hydrocolloid, or thin foam. Since ease of use is also a factor, a thin hydrocolloid is selected for topical therapy. A home care nurse is also recommended to follow up on teaching the patient how to care for the pressure ulcer and strategies on how to prevent further ulcerations. Mrs. Johnson is also to follow up with the NP in 1 month. For patients who develop extensive ulcers, the NP should refer the patient to an expert near the patient’s home. Primary care NPs often face the challenge of pressure ulcer care in the outpatient setting. They must make recommendations on how to care for these wounds. The focus of interventions should be on eliminating the causative factors and correcting systemic Volume 8, Issue 9, October 2012
Table 1. Dressing Categories and Examples Dressing Type
Examples
Hydrogel
Skintegrity (Medline), Duoderm (Convatec)
Film
Tegaderm (3M), Opsite (Smith and Nephew), Bioclusive (Ethicon)
Composite
Tegaderm absorbent clear acrylic dressing (3M), Covaderm Plus (DeRoyal)
Hydrocolloid
Restore (Hollister), DouDerm (Convatec), Comfeel (Coloplast)
Hydrofiber
Aquacel (Convatec)
Alginate
AlgiCell Alginate (Derma Sciences), Curasorb Calcium Alginate (Covidien), ExcelGinate (MPM Medical)
Superabsorbant
Optilock (Medline), Exu-Dry (Smith and Nephew), Xtrasorb (Derma Sciences, Inc.)
Hydrating impregnated gauze
Curasol Gel Saturated Dressings (Healthpoint Biotherapeutics), SOLOSITE Gel Conformable Wound Dressing (Smith and Nephew)
Collagen
Stimule Collagen Gel (Southwest Technologies, Inc.), Puracol Plus (Medline Industries), Promogran (Ethicon)
Foam
Mepilex (Mölnlycke), Kendal Foam Wound Dressing (Covidien), PolyMem NonAdhesive Dressings (Ferris Mfg. Corp)
Foam cavity dressing
Allevyn Cavity Wound Dressing (Smith and Nephew), Tielle Packing Hydropolymer Non-Adhesive Dressing (Ethicon)
issues associated with pressure ulcer formation. By focusing of prevention, the NP can help to ease the burden of care for pressure ulcers, which are on the rise in the community. References 1. Russo CA, Steiner C, Spector W. Hospitalizations Related to Pressure Ulcers among Adults 18 Years and Older, 2006. HCUP Statistical Brief #64. Online. December 2008. http://www.ncbi.nlm.nih.gov/books/NBK54557/. Accessed September 7, 2012. 2. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcer: Clinical Practice Guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009. 3. Pieper B. Pressure ulcers: impact, etiology, and classification. In: Bryant RA, Nix DP, eds. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Elsevier; 2011: 123-136. 4. Nix DP, Mackey DM. Support surfaces. In: Bryant RA, Nix DP, eds. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Elsevier; 2011: 154-167. 5. Norton L, Coutts P, Sibbald RG. Beds: practical pressure management for surfaces/mattresses. Adv Skin Wound Care. 2011;24(7):324-332. 6. Centers for Medicare and Medicaid Services. Medicare Policy Regarding Pressure Reducing Support Surfaces MLN Matters Number: SE1014 Online. August 2010. https://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNMattersArticles/downloads//SE1014.pdf. Accessed September 7, 2012. 7. Stotts NA. Nutritional assessment and support. In: Bryant RA, Nix DP, eds. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Elsevier; 2011: 388-399. 8. Rolstad BS, Bryant RA, Nix DP. Topical management. In: Bryant RA, Nix DP, eds. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Elsevier; 2011: 289-306.
specializing in wound, ostomy, and continence care. She is a director at large with the Wound, Ostomy, and Continence Nursing Society and can be reached at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest. 1555-4155/$ see front matter © 2012 American College of Nurse Practitioners http://dx.doi.org/10.1016/j.nurpra.2012.09.015
Carole Bauer, MSN, ANP-BC, OCN, CWOCN, works at the Karmanos Cancer Center in Detroit as a nurse practitioner www.npjournal.org
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ABSTRACT Many consider pressure ulcers a problem only for long-term care or acute care.Yet many people are admitted to the acute care setting with a pressure ulcer that has occurred while they are residing at home. For the nurse practitioner in primary care, recognizing the alterable causes of a pressure ulcer and implementing corrective action may prevent the development of a pressure ulcer or halt the progression of a pressure ulcer before a patient requires complex management, including debridement and possible hospitalization. Keywords: decubitus ulcer, pressure ulcer, pressure ulcer prevention, pressure ulcer treatment, wounds © 2012 American College of Nurse Practitioners
I
n 2008, the Agency for Healthcare Utilization and Quality (AHRQ) reported on the 2006 results of the Healthcare Cost and Utilization Project (HCUP) as it related to hospitalizations for pressure ulcers. This document reports an 80% increase in hospitalizations where a pressure ulcer was noted as either a primary or secondary diagnosis for the admission, compared to data from 1993. The majority of patient admissions for which a pressure ulcer was noted were for a primary diagnosis other than pressure ulcer.1 Based on these data, a clinician can conclude that the number of patients living with such an ulcer is rising. Many patients are admitted to hospitals with pre-existing pressure ulcers or are being discharged to primary care with one. Primary care nurse practitioners (NPs) see patients across the lifespan and the spectrum of care. It is important to be aware of changes that may occur as a result of aging or progressive illness that increase the likelihood that a patient may develop a pressure ulcer in any setting, including the outpatient setting. Mrs. Johnson is one such www.npjournal.org
example of a patient who has developed a pressure ulcer in an outpatient setting. She is a 76-year-old woman with a history of breast cancer, hypertension, asthma, and diabetes. She has recently completed a 6-month course of chemotherapy and has had a progressive weight loss over the past 6 months. She presents in the primary care clinic for a 3-month appointment related to her hypertension, asthma, and diabetes. She normally arrives at her appointments independently, but today she is accompanied by her daughter and is sitting in a wheelchair. She and her daughter report that she has had a decreased appetite over the past 6 months, at times eating less than half of her regular meals. They also report that although she has completed her chemotherapy, she has not yet regained her strength. She is spending a good deal of time at home sitting in a chair. They report that the patient has a sore on her “tailbone.” In addition to her normal care for her hypertension and diabetes, Mrs. Johnson and her daughter are looking for help with the management of this sore. The Journal for Nurse Practitioners - JNP
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Figure 1. Pressure Ulcer Stages
Figure 1A. Stage I: Unblanchable erythema.
Figure 1B. Stage II: Partial thickness skin loss.
Figure 1C. Stage III: Full thickness skin loss.
Figure 1D. Stage IV: Full thickness skin loss with involved supporting structure.
Figure 1E. Suspected deep tissue injury. Purple or maroon
Figure 1F. Unstageable. Full depth is unknown as ulcer base
tissue in a localized area of intact skin.
is not visible.
730
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Volume 8, Issue 9, October 2012
A pressure ulcer is defined by the National Pressure Ulcer Advisory Panel (NPUAP) as “…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. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors has yet to be elucidated.”2 (p. 16) Pressure ulcers have an exclusive classification system, defined by the NPUAP as stages I-IV, suspected deep tissue injury, and unstageable (Figure 1). A stage I pressure ulcer, defined as nonblanchable erythema, is intact skin with an area of localized redness that does not blanch and is usually located over a bony prominence. A stage I ulcer may be difficult to determine in dark-skinned individuals. A stage II pressure ulcer is a partial-thickness ulceration. It can present as a shallow, open ulcer. The base of the ulcer is pink, and there is no slough tissue present in the wound bed. It may also present as a serumfilled blister. Bruising will not be present. A stage III ulcer is full-thickness skin loss. Subcutaneous tissue may be visible in the wound bed. Slough may be present, but it does not prevent the clinician from seeing the full depth of tissue destruction. Depending on the location of the ulceration and the underlying structures, the depth of a stage III ulcer may vary. Stage IV ulcers are also full-thickness ulcers, but there is also exposed bone, tendon, or muscle noted in the wound bed. Slough or eschar may also be present in this stage. An unstageable pressure ulcer has an unknown full depth of ulceration from the presence of slough or eschar. Until the slough or eschar is removed to expose the base of the wound bed, an ulcer with these characteristics cannot be staged. The final stage of pressure ulceration is suspected deep tissue injury. This is purple or maroon tissue in a localized area of intact skin. This stage of ulceration may also be a blood-filled blister and may rapidly expose additional layers of tissue destruction, even with optimum treatment.2 The major cause of pressure ulcers is pressure, but several other factors play a key role in determining at what level of pressure a patient will develop an ulcer. The intensity and duration of the pressure, as well as tissue tolerance, are key determinants in ulcer development. There is an inverse relationship between duration www.npjournal.org
and intensity in ischemia development, which results in pressure ulcer development. Long periods of low intensity pressure result in ulceration, just as high intensity pressure over a short period will also result in ulceration. Tissue tolerance refers to the “…integrity of the skin and supporting structures that influence the skin’s ability to redistribute the applied pressure.”3 (p. 128) Both intrinsic and extrinsic factors affect tissue tolerance and include shear, friction, moisture, nutritional debilitation, advanced age, low blood pressure, stress, smoking, elevated body temperature, and other miscellaneous factors that impair blood flow.3 Each of these factors can be assessed by a structured risk-assessment scale. According to the NPUAP, each health care setting should have a policy that recommends evaluating patients for their risk of pressure ulcer development. For Mrs. Johnson, several confounding issues may have led to the development of her pressure ulcer. Assessment for risk in the primary care setting may help to prevent patients from developing pressure ulcers at home. As Mrs. Johnson is evaluated in the primary care clinic, a structured risk assessment should include the following parameters, documented in the NPUAP guidelines for pressure ulcer prevention and treatment: 1. Activity and mobility: Individuals who are bedfast or chairfast should be considered at risk for pressure ulcer development. 2. Skin condition: Any patient with an alteration to intact skin should be considered at risk for pressure ulcer development. 3. Physical condition: Several factors have been determined to increase a patient’s risk to develop a pressure ulcer: a. Nutritional indicators, such as hemoglobin, anemia, serum albumin levels, and weight b. Factors affecting perfusion and oxygenation, such as diabetes, cardiovascular instability, low blood pressure, and oxygen use c. Fecal and urinary incontinence and general skin moisture d. Advancing age e. Friction and shear. Generally, as mobility and activity decrease, friction and shear increase.2 The assessment of Mrs. Johnson’s wound should include a history of the wound and the treatment that she and her daughter have been doing at home. Key The Journal for Nurse Practitioners - JNP
731
components of this assessment will include how long she has had the wound. Has she noticed anything making the wound worse or better? Has she had a wound in this location in the past? If so, what treatment did she use to heal it? What is their current treatment? Are they washing it with anything in particular? Is there a dressing in place? Are they using any home remedies on the wound? Frequently, patients and families will have home remedies that, in fact, make a wound worse rather than better. These home remedies can include cleaning the wound with alcohol, peroxide, and betadine, which are known toxins to granulocytes and will not promote healing. A second common factor to explore during the patient interview is to determine where the patient is sleeping and what equipment in the home the patient is using. Many patients with respiratory issues sleep in reclining chairs at home and are unable to reposition themselves during sleep. Home medical equipment, such as bedside commodes, shower chairs, and other lifting devices, can contribute to friction and shear and thus increase the incidence of pressure ulcer formation. Is physical or occupational therapy indicated? During Mrs. Johnson’s interview, the clinician determines that she is not only spending long periods in a wheelchair during the day, but she is also sleeping in a recliner at home at night. She has never had a wound in this location before, but it has been present for 30 days. She and her daughter have been cleaning the wound with hydrogen peroxide and placing a bandage with over-the-counter triple antibiotic ointment on it when the patient bathes every other day. On assessment, Mrs. Johnson has developed a stage II pressure ulcer (partial thickness skin loss) and thus requires interventions to relieve the cause of the ulcer and correct underlying systemic conditions that may have contributed to its development, as well as appropriate topical therapy. Mrs. Johnson’s assessment reveals that she has several factors that place her at risk for pressure ulcer development. She is now chairfast for much of the day and requires a seating surface that is able to redistribute the pressure when she is in it. Additionally, she should be on a sleep surface that also redistributes the pressure. A sleep surface is necessary because of lessening tissue tolerance from repeated exposure to pressure. Support surfaces for both the chair and the bed are available 732
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from durable medical equipment companies and should be a medical-grade surface. Suppliers who participate with Medicare can be located at www.medicare.gov/ Supplier. These vendors can help determine the appropriate support surface for the patient at risk for a pressure ulcer or who has already developed one. The choice of a support surface should be individualized to meet the patient’s needs. Support surfaces are categorized as either reactive or active surfaces. A reactive support surface is “a powered or nonpowered support surface with the capability to change its load distribution properties only in response to applied load.”2 (p. 129) An active support surface is “a powered support surface with the capability to change its load distribution properties, with or without applied load.”2 (p. 129) Reactive support surfaces are appropriate for pressure ulcer prevention in combination with a turning schedule. This type of support surface, with few exceptions, is appropriate in the home setting.4 Examples of reactive surfaces include those filled with gel, foam, air, or a combination of foam and air. In 2008, Norton, Coutts, and Sibbald developed the Support Surface Selection Tool, a decision tree to help clinicians determine which support surface would be appropriate. This decision tree has since been expanded to include an algorithm that takes into consideration patient-specific criteria and features of the support surface classification chosen (ie, active or reactive). This decision tree can be useful in guiding the primary care provider to specify features that may help prevent pressure ulcers.5 The Centers for Medicare and Medicaid Services (CMS) define support surfaces into 3 groups to guide reimbursement. Beneficiaries must meet specific criteria for a surface to be eligible for reimbursement. Groups 1 and 2 surfaces are designed to replace existing mattress systems, while Group 3 is a complete bed system. CMS policy defines down the groups as follows: • Group 1—A group 1 support surface is covered if the patient is completely immobile. Otherwise, he or she must be partially immobile or have any stage pressure ulcer and demonstrate 1 of the following conditions: impaired nutritional status, incontinence, altered sensory perception, or compromised circulatory status. A physician order must be obtained prior to delivery of the equipment and should be kept on file by the supplier. Volume 8, Issue 9, October 2012
• Group 2—A group 2 support surface is covered if the patient has a stage II pressure sore located on the trunk or pelvis, has been on a comprehensive pressure sore treatment program (which has included an appropriate group 1 support surface for at least 1 month), and has sores which have worsened or remained the same over the past month. A group 2 support surface is also covered if the patient has large or multiple stage III or IV pressure sores on the trunk or pelvis, or if he or she has had a recent mycutaneous flap or skin graft for a pressure sore on the trunk or pelvis and has been on a group 2 or 3 support surface. • Group 3—A group 3 support surface is covered if the patient has a stage III or IV pressure ulcer, is bedridden or chair-bound, would be institutionalized without the use of the group 3 support surface, is under the close supervision of the patient’s treating physician, at least 1 month of conservative treatment has been administered (including the use of a group 2 support surface), a caregiver is available and willing to assist with patient care, and all other alternative equipment has been considered and ruled out.6 (p. 4) Based on Mrs. Johnson’s score on the support surface selection tool, a hospital bed with a non-powered air and foam-filled surface was chosen for her bed surface. Mrs. Johnson has reported that she spends a long time sitting in her wheelchair, thus a pressure redistribution surface for her wheelchair is also indicated. Ideally, she should be evaluated in a seating clinic by a team of providers whereby both her wheelchair and an appropriate cushion are evaluated and selected based on her size. Seating clinics are available in a variety of settings, including rehabilitation centers, physical therapy centers, and durable medical equipment providers. Mrs. Johnson’s history of poor appetite makes nutritional screening and counseling another component that is important in the assessment of her pressure ulcer. Nutritional assessment can be accomplished using standardized tools, such as the Mini Nutritional Assessment (available at www.mna-elderly.com) or Nutritional Screening Initiative tool (available at www.cdaaa.org/images/Nutritional_Checklist.pdf). Annual nutrition screening as part of a complete history and physical exam can help to identify social and environmental factors that may be alterable. Supportive nutritional therapy is a balance between energy and protein requirements and depends on many variables, such as disease status and presence and severity of a wound. A healthy person requires approxiwww.npjournal.org
mately 0.8 g of protein per kg per 24 hours and 20–35 calories/kg of body weight/24 hours,7 but according to the NPUAP, a patient at risk requires a minimum of 30–35 kcal per kg body weight per day with 1.25–1.5 g/kg/day protein and 1 ml of fluid intake per kcal per day. To achieve this goal, the NPUAP recommends offering high protein mixed oral supplements in addition to the usual diet. These supplements should be offered between meals to avoid interfering with normal food intake.2 If Mrs. Johnson were having issues with moisture, such as urinary or fecal incontinence, several basic interventions can be instituted in the primary care setting. Timed voiding, where the patient goes to the toilet on a schedule rather than on the urge to void or defecate, is a strategy that may help to decrease incontinent episodes. The patient and family can also be counseled to assess the physical environment. An assessment of the physical environment may reveal barriers to the toilet. Alleviating these physical barriers may decrease incontinent episodes. Another basic intervention includes skin protection with a barrier cream (eg, dimethicone or a zinc-based cream). At times, the use of an incontinence brief may be indicated. There are several different levels of absorption and multiple different types of products available to manage incontinence. Patients should be referred to a DME provider or Internet source (eg, National Association for Continence www.nafc.org) for resources to manage incontinence. The actual exam of Mrs. Johnson’s ulcer is the next component of her care. Assessment criteria of any wound should include location, extent of tissue loss (full thickness or partial thickness), size (length, width, and depth), a description of the character of the wound bed, and amount and type of exudate. Mrs. Johnson’s wound is located on her coccyx. It has partial thickness skin loss, so therefore it is shallow. It measures 1 cm long × 2 cm wide. The periwound skin is intact without signs of maceration. There is minimal drainage. The wound bed is 100% pink tissue. This would be characterized as a stage II pressure ulcer. The next step is to choose topical therapy for the wound. The first step in the dressing process is cleansing and irrigation. Wounds should be cleansed with each dressing change. Normal saline irrigations with a force of 4 to 15 psi are appropriate to remove surface bacteria while not inoculating the underlying tissue. The Journal for Nurse Practitioners - JNP
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Figure 2. Dressing Choice Algorithm
Key Assumptions : • Wound IS NOT infected • Wound DOES NOT require debridement
No Exudate: hydrogel, film, composite Minimal Exudate: film, composite, thin hydrocolloid, thin foam,
Shallow
Moderate Exudate: hydrocolloid, foam, alginate, hydrofiber Heavy Exudate: alginate, hydrofiber, superabsorbant, pouch
Depth of the Wound
No Exudate: hydrogel, hydrating impregnated Gauze (both require a cover dressing) Minimal Exudate: hydrating impregnated gauze, collagen, hydrogel, wound fillers (Cover dressing required)
Deep
Moderate Exudate: alginate, foam cavity dressing, absorbent impregnated gauze, collagen, superabsorbent, hydrofiber (cover dressing required) Heavy Exudate: alginate, foam cavity dressing, hydrofiber, superabsorbent, (cover dressing required) pouch
This can be done with a 19-gauge angiocatheter and a 35-ml syringe.8 Prepackaged canisters of pressurized saline are available and are good choices for patients at home. After cleansing the wound bed, a topical dressing should be applied. The type of dressing will depend on the wound bed characteristics. Amount and type of exudate, wound depth, tunneling and undermining, type of tissue present in the wound bed, and the condition of the periwound skin all play a role in determining the best dressing. There are many categories of wound dressings and many dressings in each category. Using an algorithm can make dressing selection easier (Figure 2). It is wise to become familiar with 1 dressing in each category to streamline the ordering process (Table 1). 734
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Mrs. Johnson’s wound is shallow with minimal exudate. Her wound could be managed using either a composite, thin hydrocolloid, or thin foam. Since ease of use is also a factor, a thin hydrocolloid is selected for topical therapy. A home care nurse is also recommended to follow up on teaching the patient how to care for the pressure ulcer and strategies on how to prevent further ulcerations. Mrs. Johnson is also to follow up with the NP in 1 month. For patients who develop extensive ulcers, the NP should refer the patient to an expert near the patient’s home. Primary care NPs often face the challenge of pressure ulcer care in the outpatient setting. They must make recommendations on how to care for these wounds. The focus of interventions should be on eliminating the causative factors and correcting systemic Volume 8, Issue 9, October 2012
Table 1. Dressing Categories and Examples Dressing Type
Examples
Hydrogel
Skintegrity (Medline), Duoderm (Convatec)
Film
Tegaderm (3M), Opsite (Smith and Nephew), Bioclusive (Ethicon)
Composite
Tegaderm absorbent clear acrylic dressing (3M), Covaderm Plus (DeRoyal)
Hydrocolloid
Restore (Hollister), DouDerm (Convatec), Comfeel (Coloplast)
Hydrofiber
Aquacel (Convatec)
Alginate
AlgiCell Alginate (Derma Sciences), Curasorb Calcium Alginate (Covidien), ExcelGinate (MPM Medical)
Superabsorbant
Optilock (Medline), Exu-Dry (Smith and Nephew), Xtrasorb (Derma Sciences, Inc.)
Hydrating impregnated gauze
Curasol Gel Saturated Dressings (Healthpoint Biotherapeutics), SOLOSITE Gel Conformable Wound Dressing (Smith and Nephew)
Collagen
Stimule Collagen Gel (Southwest Technologies, Inc.), Puracol Plus (Medline Industries), Promogran (Ethicon)
Foam
Mepilex (Mölnlycke), Kendal Foam Wound Dressing (Covidien), PolyMem NonAdhesive Dressings (Ferris Mfg. Corp)
Foam cavity dressing
Allevyn Cavity Wound Dressing (Smith and Nephew), Tielle Packing Hydropolymer Non-Adhesive Dressing (Ethicon)
issues associated with pressure ulcer formation. By focusing of prevention, the NP can help to ease the burden of care for pressure ulcers, which are on the rise in the community. References 1. Russo CA, Steiner C, Spector W. Hospitalizations Related to Pressure Ulcers among Adults 18 Years and Older, 2006. HCUP Statistical Brief #64. Online. December 2008. http://www.ncbi.nlm.nih.gov/books/NBK54557/. Accessed September 7, 2012. 2. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcer: Clinical Practice Guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009. 3. Pieper B. Pressure ulcers: impact, etiology, and classification. In: Bryant RA, Nix DP, eds. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Elsevier; 2011: 123-136. 4. Nix DP, Mackey DM. Support surfaces. In: Bryant RA, Nix DP, eds. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Elsevier; 2011: 154-167. 5. Norton L, Coutts P, Sibbald RG. Beds: practical pressure management for surfaces/mattresses. Adv Skin Wound Care. 2011;24(7):324-332. 6. Centers for Medicare and Medicaid Services. Medicare Policy Regarding Pressure Reducing Support Surfaces MLN Matters Number: SE1014 Online. August 2010. https://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNMattersArticles/downloads//SE1014.pdf. Accessed September 7, 2012. 7. Stotts NA. Nutritional assessment and support. In: Bryant RA, Nix DP, eds. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Elsevier; 2011: 388-399. 8. Rolstad BS, Bryant RA, Nix DP. Topical management. In: Bryant RA, Nix DP, eds. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Elsevier; 2011: 289-306.
specializing in wound, ostomy, and continence care. She is a director at large with the Wound, Ostomy, and Continence Nursing Society and can be reached at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest. 1555-4155/$ see front matter © 2012 American College of Nurse Practitioners http://dx.doi.org/10.1016/j.nurpra.2012.09.015
Carole Bauer, MSN, ANP-BC, OCN, CWOCN, works at the Karmanos Cancer Center in Detroit as a nurse practitioner www.npjournal.org
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