Implementation of a standardized protocol for treating pressure ulcers in a nursing home

Implementation of a Standardized Protocol for Treating Pressure Ulcers in a Nursing Home Developing a standard protocol for decubitus treatment proves beneficial for both staff and patients. BY JEAN

BECKEL

edsore, decubitus ulcer, or pressure ulc e r - r e g a r d l e s s of the terminology used, the result for the patient and the nurse is the same. Painful, often open areas put patients at risk of further complications from infection. The nurse, in collaboration with the physician, has the c h a l l e n g e o f achieving and maintaining intact skin integrity and decreasing the risk of complications. Pressure ulcers are " . . . localized areas in which necrosis of skin and subcutaneous tissue has been produced by pressure. Pressure interferes with the blood supply of the tissue and, if prolonged, will cause tissue death. ''1 Many factors can put the patient at risk for the development of pressure ulcers. These include chronic illness, immobility, circulatory problems, anemia, emaciation, decreased sensation or paralysis, obesity, and altered mental status. Most elderly patients in our long-term care facility have several of these conditions. A review of 95 current residents in our facility showed that many were being treated for pressure ulcers. The specific treatment for a given patient depended on both the prescribing physician and the nurse initiating the treatment. For example, nursing staff often relied on standing orders that allowed them to choose from a variety of ointments that could be used on reddened skin. This resulted in nurses choosing their particular "favor-

B

JEAN BECKEL,RN, BSN, is assistant director of nursing and infection control coordinatorat the Assumption Homein Cold Spring, Minnesota. 34/1]37075

84 Geriatric Nursing March/April 1992

ite." Many times the treatment for a given patient varied, depending on the nurse on duty during each shift. It was concluded that a standardized protocol was needed that could be beneficial in reducing both the number of ulcers and healing time. We first reviewed the great assortment of products available for the treatment of pressure ulcers in search of one that could be used on a variety of wounds while promoting healing in all stages of such ulcers. We focused on Granulex (Dow B. Hickam, Inc., Sugar Land, Texas), an aerosol product containing 0.1 mg trypsin, 72.5 mg balsam Peru, and 650 mg castor oil per spray application (approximately 1.2 seconds) that has a long history of use in both acute and long-term care facilities. Although we focused on Granulex, multiple treatment options were included versus conducting a study of, for example, only two products to gain staff commitment to standardization.

We then developed a protocol for presentation at our quarterly Utilization Review Committee meeting in October 1989. Four physicians who provided care for more than 90% of our patients were present along with the administrator, director of nursing, assistant director of nursing, consulting pharmacist, dietary manager, and social services director. Current treatment techniques and the rationale for the protocol were discussed. Summaries of these items and copies of research articles related to pressure ulcer management and wound healing 2-11 were distributed before the meeting. Each stage of wound management was discussed, and a trial protocol resulted.

(See "Development of Standardized Protocol for Treatmeet of Pressure Ulcers.") All agreed to a 3-month trial, with results to be reported at the next meeting. Ulcer severity was defined as follows (see figure, p. 86): • S t a g e / - - A r e a of skin with soft-tissue swelling, erythema, and heat. 8 Discoloration does not disappear within 15 minutes or when pressure has been relieved. • Stage 2mArea of broken or blistered skin with only epidermal involvement. It may be clean, infected, or necrotic. • Stage 3 - - A r e a of broken skin with involvement

DEVELOPMENT OF STANDARDIZED PROTOCOL FOR TREATMENT OF PRESSUREULCERS r

Trial

Stage/Description ,, , ,

Preulcer/skin discoloration that disappears within 15 minutes I Skin discoloration that does not disappear within 15 minutes after pressure has been relieved 2 Broken or blistered skin with only epidermal involvement; may be dean, infected, or necrotic

3 Broken skin with dermal involvement; may be either clean, infected, or necrotic 4 Broken skin with bone and muscle tissue involvement; may be either clean, infeded, or necrotic.

,,,,

,,,,,

,,,

,

Protocol

..

,

Turn patient every 2 hours. Massage area with lotion bid (am and hs). Obtain physician order for pressure relief or comfort device when available. Tum patient every 2 hours. Obtain physidan order for pressure relief or comfort device when available. Eflteurage area with Granulex every shift. OR Apply transparent dressing if caused by friction rub only (no dressing on pressure breakdown areas). Clean: NS irrigation; then spray Granulex in wound and around edges. Repeat every shift. A nonadhering (oil emulsion) dressing may be applied. OR Apply occlusive to transparent dressing to affected area. Must leave on for 5 to 7 days. Infected: Irrigate with his every shift and apply topical antibiotic as specified per physiciao order until clean. Then treat as above. Necrotic: Irrigate with NS. Apply chemical debrider to dead tissue. Cover with gauze dressing per physician orders. ORApply wet-to-dry dressing to dead tissu.e per physician order. Qeam Same as for stage 2 Infected: Same as for stage 2 Necrot/o Same as for stage 2 Treat the same as stage 2 or 3 unless tunnels or fistulas; then use the followings Clean: Oebride as necessaryper phyddan order; then irrigate with NS. Saturate gauze packing with Granulex per physician order. Loosely place gauze into all pockets and cavities. Repeat every

shift. Infected: Irrigate with NS and apply

gauze covered with a topical ant~iotic as specified per physician order. Repeat every shift. OR Rinse with NS. Necrotic: Apply chemical debrider to dead tissue with gauze. OR Apply wet-to-dry gauze to dead tissue. N5, Normalreline solution;bid, ~

j ,

Real Protocol Turn patient every 2 hours. Massage area with lotion bid (am and hs). Obtain physician order for pressure relief or comfort device when available. Turn patient every 2 hours. Obtain physician order for pressure relief or comfort device when available. Effleurage area with Granulex every shift.

Clea~. N$ irrigation; then spray Granulex

in wound and around edges. Repeat every shift. A nonadhering (oil emusion) dressing may be applied. Infected: Irrigate with NS every shift and apply topical anh~aioticas specified per physician order until clean. Then treat as above. Necrotic: Apply wet-to-dry dressing to dead t~ue per physician order.

Clean, Same as for stage 2 Infecte~ Same as for stage 2

Necrot/c~ Same as for stage 2 Treat the same as stage 2 or 3 unless tunnels or fistulas; then use the following: C/can.*Debrideas:necessary per physician order; then irrigate with NS. Saturate gauze packing with Granulex per phySician order. Loosely place gauze into all pockets and cavities. Repeat every shift Infected: Irrigate with NS and apply gauze covered with o topical antibiotic as specified per physician order. Repeat ever shift. OR Rinse with NS every shift. Necrotic: Apply wet-to-dry gauze packing to dead tissue.

o day; am, morning;hs, at bedtime.

Geriatric Nursing March/April1992 85

WEEKLY DECUBITUS REPORT Patient name: Med rec ~ :

Form 1

Date first observed: Site: Stage: Size: Drainage: Odor: Granulation: Date

a,~ed bD/C

Location

rec =

Treatment started:

Add

cm

Stage

Date healed: Diameter (cm)

Drainage

Odor Y/N d

# = medical number discontinue

Do the following: Dietat3" sheet Care plan MARc Supplies ordered Date Dr. Notified

Progress/assessment

D/C b

Nurse sig

CMAR = medication administration record d Y/N = yes or no

Format for Form 1, which was used to monitor pressure ulcer(s) for a given patient.

Oerm,s

Subcutaneous

~----~------_ ~ - - - ~

j

uusae.-."~'~ Ep)cle~

~.

GradeII

Dermis Subcutaneous

Musci-''~" e Jf"~~~-~-~'"~GradeItl i

Subcuatneou .s-o, . ~~- o ~ Fat

Muscl~e

i

GraIVde Mus~ cle ~ Bone .~

86 Geriatric Nursing March/April 1992

through the dermis and into the subcutaneous tissue. It may be clean, infected, or necrotic. • S t a g e 4--Area of broken skin with bone and/or muscle tissue involvement. It may be clean, infected, or necrotic. Stage 1 wounds were treated with Granulex or covered with a transparent dressing. Stages 2, 3, and 4 wounds were to be irrigated with normal saline solution and then treated with Granulex or an antibiotic ointment as appropriate. Nonadhering (Oil emulsion, Sparta, Haywood, California), transparent film (Opsite, Smith-Nephew, Massillon, Ohio; Tegaderm, 3M, St. Paul, Minnesota), or occlusive (Duoderm, Convatee, Princeton, New Jersey; Restore, Hollister, Libertyville, Illinois) dressings were also used, depending on the type of pressure ulcer. Nursing staff had an element of choice in treatment, as outlined by the physicians, to evaluate various treatments. The next task was to educate the nursing staff so that a team approach to pressure ulcer treatment could be instituted, and several in-services were held for all nursing staff. Our objectives were to enable the staff to consistently and correctly identify, stage, report, and track patient pressure areas, understand the rationale for the recommended changes in treatment, and consistently apply a correct treatment based on their evaluation. Nursing assistants began to understand their role in observation of new and existing pressure areas and the importance of reporting their findings to the licensed nursing staff. Pressure area comfort and relief interventions and their importance to the patient were reviewed. Nursing assistants (the staff members with the most direct patient care) became the eyes and ears of the licensed nursing staff. Their role was essential in early identification of pressure areas. The licensed practical nurses and registered nurses providing treatment reviewed the description, staging, and treatment of pressure areas and the rationale for any changes. Two tracking forms were developed for report-

UTILIZATION REVIEW STUDYmDECUBITUS TREATMENT TRACKING FORM Stage 1 Unbroken skin discoloration pa 15 minutes. Treatment can be initiated by nursing staff. (Form 2, Page 1) Treatment begun

Opsite transparent Open at Decub b Etiteurage Ettleurage d s ~ - - f r i c t i o n Date Date Decub Decub Rxe No. days stuab, Pt. name where only c a Granulex rub only started ended healed changed to heal end

Stage 2 Broken or blistered with

Stage 3 Broken skin with dermal

Stage 4 Broken skin with b o n e and

epidermal involvement Treatment of infected (I) or necrotic (N) requires MD order. (Form 2, Page 2)

involvement. All treatment requires MD order. (Form 2, Page 3)

muscle tissue involvement. All treatment requires MD order. (Form 2, Page 4)

PL name

Treatment begun ReOpsite store NS ir i c NS ir c Decub Cf, I tran# occl h Granu- antiwhere or N dsg dsg lex biotic

a p ~ after decubitus ulcer c dsg = dressing

b Decub

~

Elase NS i r c chemical de- Wet> Date Date Decub Decub Rx brider dr3, dsg started e n d e d healed change d

d C = with e R x = treatment/treated f C = clean

No. days to heal

Open at study end

g tran$ ~ transparent hoccl = occlusive i N S i r ~ normal saline irrigation

Format for Form 2, which was used to tabulate individual data from Form 1.

ing the progress of treatment. The first was a single-page form started by the nursing staff on discovery of a pressure ulcer and added to the patient's chart. The second was a four-page form used only during the study to tabulate the first form by stage of ulcer, one page for each stage. The licensed staff initially reacted with skepticism and some reluctance to relying on an established protocol. Nurses had been accustomed to initiating treatments with products of their own choosing, and thus there was a transition period as they became more comfortable with staging pressure ulcers and using treatments based on their assessments. The staff quickly gained confidence in the new program, however, as results became available. The trial protocol was followed for 12 weeks. At that time the results were presented to the Utilization Review Committee. Eighty-five ulcers in 45 patients had been treated and tracked for varying periods of time. The physicians concluded that a final protocol should be developed with a single treatment for each stage of pressure ulcer. They believed, however, that more data were needed

before making any final decisions and recommended continuing the trial for an additional 12 weeks. When the Utilization Review Committee made their decisions regarding a final protocol, further instructions were given to the staff to alter treatment based on their assessments. Results from the two 12-week periods were combined.

(See "'Decubitus Treatment Utilization Review Study Results.") Over a period of 24 weeks, a total of 173 ulcers had been treated in 59 patients, ages 56 to 98 years, with most ulcers being stage 1 and stage 2. Note that some patients had more than one ulcer during the course of the study, and many ulcers were treated in both periods although perhaps at a different stage. Stage 1 Ulcers Most patients with stage 1 pressure ulcers received Granulex spray followed by eftteurage (light massage) to the affected area. Thirty-one of the 49 ulcers treated with Granulex healed, with an average healing time of 10 days. One patient received effteurage only and the ulcer

Geriatric Nursing March/April 1992 87

DECUBITUS TREATMENT UTILIZATION REVIEW STUDY RESULTS (OCT. 15, 1989, TO MAR. 31, 1990) Treatment Initialed

No. of Ulcers

Avg. No. of Days Treated

No. of Ulcers Healed

No. Changed to New Treatment

No. Not Healed

Stage I Eflteumge with Granulex Eftteurage only Transparent dressing Stage 2

49 1 8

14.5 g 13

31 ! $

10 0 3

8 0 0

19 12 67

31 20 17.5

tI 8 49

3 4 11

5 5 7

7

26.5

4

3

0

0

.

3

34

1

1

1 0 2

t40 . 27

1

0

I

t

0

1

10

0

1

0

1

78

0

0

1

2

38

0

2

0

Occlusive dressing

Transparent dressing his ~rrigatMn and Granulex N$ irrigation and anh'blotic NS irrigation and chemical debrider Wet-to-dry dressing Stage 3 Occlusive dressing

Transparent dressing NS irrigation and

.

.

.

I 0 .

.

.

Granulex NS irrigation and ant~Jatic NS irrigation and chemical debrider Wet-to-dry dressing NS, Norma/sarmer,o/u//on. *Average includes change~ to new treatment and

dropout~.

healed. Eight ulcers were treated with transparent film dressings. Of these, five healed and treatment for three was changed. Average healing time for those that healed was 17 days. On the basis of these findings, the physicians continued the Grannlex with effleurage treatment for stage 1 ulcers in the final protocol. A staff concern with stage 1 ulcers was treatment of skin-on-skin reddened areas, typically found under the breasts, in abdominal folds, or occasionally in the groin and thigh areas. Before treatment with Granulex and effleurage was begun, the possibility of fungal infection first needed to be considered and, if present, appropriately treated. Stage 2 Ulcers Most ulcers treated were stage 2. Nineteen clean stage 2 ulcers were treated with occlusive dressings and 12 with transparent dressings. Eleven ulcers in the occlusive dressing group and eight in the transparent dressing group healed; average healing times were 27 and 22 days, respectively. Sixty-seven clean stage 2 ulcers were irrigated with normal saline solution and then treated with Granulex. Forty-nine healed, with an average healing time of 16 days. Seven infected stage 2 ulcers were irrigated with normal saline solution and then treated with an antibiotic ointment. Four healed, with an average healing time of

88 Geriatric Nursing March/April 1992

37 days. Healing times may have been extended, however, because of application of the antibiotic beyond the time when the wound became "clean." Nursing staff were not changing the treatment to that of a clean wound when the signs and symptoms of wound infection were gone, although this change was stated in the protocol. Three necrotic stage 2 ulcers were treated with wet-to-dry dressings. One healed in 22 days. On the basis of the success of Granulex, treatment of clean stage 2 wounds in the final protocol was limited to saline solution irrigation followed by application of Granulex. Treatment for infected stage 2 wounds remained the same except for clarification regarding the duration of antibiotics; and, as a result of physician preference, treatment of necrotic stage 2 wounds was limited to wet-to-dry dressings. Stage 3 a n d Stage 4 Ulcers Stage 3 data were limited and no patients were identified as having a stage 4 pressure ulcer. Decisions regarding a final protocol for these stages were therefore based on physician judgment. Reactions to t h e S t u d y Physicians believed that the nursing staff was better able to evaluate pressure ulcers; therefore, when a physician received a call regarding an ulcer, they also re-

ceived accurate assessment information. In addition, physicians believed that nurses were better able to differentiate between ulcers and other types of skin conditions that needed medical attention. Physicians also perceived that patients were benefiting from early recognition of stages 1 and 2 pressure ulcers by nursing staff and implementation of a consistent treatment protocol. Finally, physicians believed that choice of treatment had been optimized. That is, if a pressure ulcer failed to respond within a reasonable time, as indicated by data from the study, the physician could promptly consider alternative therapies. This, in turn, saved time and costs. Nursing staff also had a positive reaction to the study. Namely, they were able to accurately assess pressure areas, the need for treatment, and which treatment to begin. This was the result of a team approach in the identification of pressure ulcers and consistency in treatments and charting of assessment information. With our interdisciplinary approach to patient problems, nutritional intervention has since been added to the final protocol. If a patient is identified as having a stage 2, 3, or 4 pressure ulcer, nutritional supplementation with vitamin C and protein is included. Our standardized protocol will continue to be evalu-

ated, as will the use of new products as they appear in the marketplace. Our goals for our patients and staff have been met, with improved patient conditions and increased staff education, awareness, and teamwork.

SlY,F-EVALUATION OF LEARNING, FOR K I ~ P. 80 Objectives: T h e r e a d e r s h o u l d be able to

3. The presence of a light-colored urine and a mild nocturia in a healthy older person might be attributed to A. Altered intake and output ratios B. Increased specific gravity of the urine C. Decreased concentrating ability in the kidney D. Increased levels of antidiuretic hormone (ADH) 4. An early sign of drug toxicity in an older adult is A. Urine that is dark orange in color B. Hyponatremia C. Renal failure D. Altered mental status 5. The potential for dehydration in an older person is a threat for all but one of the following reasons. Which one is the exception ? A. Decreased ability to concentrate urine B. Diminished ADH response C. Decreased sensation of thirst D. Decreased ability to excrete urine 6. The Cockcroft-Gault formula is A. Used to calculate therapeutic drug doses in older people B. An age-adjusted method to estimate GFR C. A formula to determine appropriate chemical-fluid balance ratios D. A term used when 24-hour urine specimens are collected from older people 7. In the absence of contraindicating conditions, average fluid intake for an older person should be A. Less than 1500 cc/day B. 1500 to 2500 c.c/day C. 2500 to 3500 cc/day D. No more than 2500 cc/day F o r a n s w e r s s e e p a g e 93.

1. Identify selected changes that occur in the structure of the renal system with aging 2. Discuss potential physiologic alterations in blood flow, glomerular filtration rate (GFR), concentration and dilution mechanisms, acid-base balance, and sodium and potassium exchange that may occur in the aging kidney 3. Define two methods of estimating creatinine clearance (GFR) in older people 4. Discuss pharmacologic issues as they relate to altered physiology in the aging kidney 5. Identify nursing parameters for assessment and interventions that incorporate knowledge of age-related changes in the physiology of the renal system Test q u e s t i o n s

1. Which of the following is considered to he a normal anatomic change in the structure of the aging kidney? A. A compensatory increase in total renal mass B. A decrease in the number of functioning glomeruli C. Enlargement of the proximal tubule D. Loss of the basement membrane 2. A "normal" serum creatinine level may not be an accurate indicator of the GFR of older people because A. Muscle mass and thus creatinine production decrease with aging B. Reductions in physical activity adversely affect serum creatinine levels C. Altered blood flow in the kidney affects creatinine exchange D. Serum creatinine levels are more reflective of changed protein metabolism in older people

REFERENCES 1. Brunner LS, Suddarth DS. The Lippincott manual of nursing practice. Philadelphia: JB Lippincott, 1986:59. 2. Aronoff FR, Friedman S J, Doedens D, Lavelle KJ. Case report: transcutaneous iodine absorption. Am J Med Sci t980;279:173-6. 3. Branemark P, Ekholm R. Tissue injury caused by wound disinfectants. J Bone Joint Surg [Am] 1967;49:48-62. 4. Cowart V. Pressure ulcers preventable, say many clinicians. JAMA 1987;257:589-93. 5. Curtin J. Prevention and treatment of pressure ulcers [Letter]. JAMA 1987;257:2917-8. 6. Goren D. Use of Omiderm in treatment of low-degree pressure sores in terminally ill cancer patients. Cancer Nurs 1989;12:165-9. 7. Fowler EM. Equipment and products used in management and treatment of pressure ulcers. Nurs Clin North Am 1987;22:449-60. 8. Knight AL. Medical management of pressure sores. J Faro Pract 1988;27:95100. 9. Kozol RA, Gillies C, Elgebaly SA. Effects of sodium hypochlorite (Dakin's solution) on cells of the wound module. Arch Surg 1988;123:420-3. 10. Lineaweaver W, McMorris S, Soucy D, tloward R. Cellular and bacterial toxicities of topical antimicrobials. Plast Reconstr Surg 1985;75:294-396. 11. Rodeheaver G, Bellamy W, Kody M, et al. Bactericidal activity and toxicity of iodine-containing solutions in wounds. Arch Surg 1982;I 17:181-6.

Geriatric Nursing March/April 1992 89