2. DEFINITION
“A pressure ulcer is 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 is yet to be elucidated”
NPUAP/EPUAP 2009
Decubitus ulcer is NOT synonymous with
pressure ulcer as decubitus implies lying
position or bed confined.
3. MAGNITUDE OF THE PROBLEM
NYSDOH “War on the Sore” 2007
NYS overall nursing home PU prevalence is
9.1% (5% target). Ranks #32 in nation.
1999 study of 42,817 pts in acute care facilities
across U.S. showed PU prevalence of 14.8%,
with nosocomial PU rate of 7.1%
(Amlung, et al; 1999)
1999 analysis reported $2.2 – $3.6 billion dollar
cost associated with1.6 million PU’s annually.
(Beckrich,Aranovich; 1999)
4. PRESSURE ULCERS AND LITIGATION
Perceived by public (and advertised by lawyers) as
poor quality care, ie, PU = Negligence!
1987 OBRA legislation stated “a resident who enters
a facility without a pressure sore does not develop
pressure sores unless the individual’s clinical
condition demonstrates that they were unavoidable”
(Meehan and Hill; 2001)
Avoidability and preventability are key!
Based on initial risk evaluation, and documentation
Most common reason for nursing home lawsuits!
5.
6. PATHOPHYSIOLOGY
Old Hypothesis: Pressure on trapped soft
tissues exceeds mean capillary pressure leading
to ischemia and necrosis.
Now Understood: First evidence of damage in
subcutaneous tissue with epidermis showing no
signs of necrosis until quite late.
Epidermal cells more able to withstand lack of
oxygen than metabolically more active tissues.
Final pathway to PU is hypoxia/ischemia
The skin is an organ; it can fail like other organs!
Witkowski and Parish; 1982
7. THERMODYNAMICS, METABOLISM AND
PRESSURE
Thermodynamic factors in skin/surface interface
As temperature increases, skin becomes more
metabolically active and 02 demands increase
With increased pressure, metabolic demands
not able to be met and skin becomes hypoxic
Hypoxic skin more susceptible to breakdown
Adding friction and shear to already fragile skin
is “perfect storm”
8. THE 4 FORCES
Pressure: Force applied to soft tissue between
hard surface and bony prominence
Friction: Resistance of one body sliding or
rolling over another
Shear: Contiguous tissues sliding relative to
each other parallel to their plane of contact
Strain: Tissue deformation in response to
pressure
10. PRESSURE ULCER STAGING
NPUAP – Nat. Pressure Ulcer Advisory Panel
Most recent revision in 2007
Consists of 4 stages plus unstageable and DTI
Many limitations and criticisms but widely
accepted and utilized
Many misconceptions and tends to be subjective
Shea system (1975) most widely used through
the 80’s and similar to NPUAP, I – IV plus closed
NPUAP/EPUAP 2009 – minor modifications
11. 2009 NPUAP – EPUAP GUIDELINES
More information and discussion – doesn’t really
change what we do
Agreement on same 4 stages + DTI and Unstag.
More discussion around:
Holistic patient assessment
Changing assessment = changing treatment
Use of validated tool, ie, PUSH for progress
Assessment and management of malnutrition
Assessment and management of pain
12. STAGE 1
Viewed by NPUAP as sign of risk
“Intact skin with non-blanchable erythema of a
localized area, usually over a bony prominence”
Darkly pigmented skin may simply demonstrate
color change compared to surrounding tissue
May be painful, soft, firm, warmer or cooler than
surrounding area
BEWARE: Do not confuse with deep tissue
injury !
16. STAGE II
Updated definition to clarify for pressure ulcers
“Partial thickness loss of dermis presenting as a
shallow open ulcer with a red or pink wound bed,
without slough. May also present as an intact or
open/ruptured serum-filled blister”
Blood blisters indicate damage deeper than
dermis and are not stage II
Should not be used to describe skin tears, tape
burns, maceration, dermatitis or denudement
19. STAGE III
Goal of update was to address variations in
appearances of stage III PU’s
“Full thickness tissue loss. Subcutaneous fat
may be visible but bone, tendon or muscle are
not exposed. Slough may be present but does
not obscure depth of tissue loss. May include
undermining and tunneling”
Depth of stage III varies by anatomic location
22. STAGE IV
Very little revision for 2007
“Full thickness tissue loss with exposed bone,
tendon or muscle. Slough or eschar may be
present on some parts of the wound bed. Often
include undermining and/or tunneling”
Depth varies according to anatomic location
Exposed bone/tendon usually directly visible
and/or palpable
25. UNSTAGEABLE
Goal of revision to reduce tendency to classify
any ulcer with necrotic tissue as unstageable,
when the depth of the ulcer can be seen.
“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”
If portion of base is visible – it is stageable.
Wounds obscured by appliances, dressings, etc
are NOT unstageable. Move the stuff and look!
28. DEEP TISSUE INJURY
Newest PU in updated staging system
“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”
Difficult to detect in dark skinned individuals
Commonly mistaken as stage I
May evolve rapidly in spite of optimal care as
damage already done
32. PREDICTING RISK
BRADEN SCALE: 6 parameter instrument
1) Sensation
2) Activity
3) Mobility
4) Moisture
5) Friction
6) Nutrition
High Risk: 18 or less in elderly or darkly pigmented skin
16 or less in other adults
(http://www.bradenscale.com)
33. PREDICTING RISK
BRADEN Q SCALE: 7 parameter for Peds
1) Mobility
2) Activity
3) Sensory Perception
4) Moisture
5) Friction-Shear
6) Nutrition
7) Tissue Perfusion and Oxygenation
High Risk: 16 or less (7 for modified Braden Q)
(HTTP://www.nichq.org/pdf/PUBradenQScale.xls)
34. TREATMENT OBJECTIVES
Identificationof problem
Debridement of necrotic tissue
Moist wound care without maceration
Control of infection/bioburden
Management of pain
Pressure redistribution/Offloading
Choice of wound care products is individual
preference as long as above objectives met.
36. GROUP 1 SUPPORT SURFACES
Pressure overlay, foam, air, water and gel pressure
mattresses
Covered if patient meets following criteria:
1) Completely immobile (cannot move w/o assistance) or
2) Limited mobility PLUS numbers 4-7 or
3) Any stage pressure ulcer on trunk or pelvis PLUS 4-7 or
4) Impaired nutritional status
5) Fecal or urinary incontinence
6) Altered sensory perception
7) Compromised circulatory status
37. GROUP II SUPPORT SURFACES
Powered, advanced pressure reducing
mattresses and overlays. Low air loss,
microclimate management, air fluidized therapy
Covered if patient meets following criteria:
1) Multiple stage II ulcers on trunk or pelvis AND
2) Pt has been on comprehensive PU treatment program for past
month including Group I surface and ulcers are same or
worsened or
3) Large or multiple Stage III or IV PU’s on trunk or pelvis OR
4) Recent myocutaneous flap or skin graft for PU on trunk or
pelvis (60 d) AND
5) Pt has been on a group II or III surface immediately prior to
discharge from hospital or SNF (within 30 days)
38. AVAILABLE PROTOCOLS
AHCPR (Agency for Healthcare Policy and Research.
Now known as AHRQ (Agency for Healthcare Research
and Quality).
AHCPR Clinical Practice Guideline #3: Pressure Ulcers
in Adults: Prediction and Prevention.
(AHCPR #92-0047: May 1992)
AHCPR Clinical Practice Guideline #15: Treatment of
pressure Ulcers. (AHCPR #95-0652, Dec 1994).
WOCN Guideline for Prevention and Management of
Pressure Ulcers, 2003
(www.ahrq.gov/news/pcubcat/c_clin.htm#clin014)
(www.wocn.org)
39. COMMON SENSE !
Document complete initial skin evaluation on day of
admission wherever you are (ED, OR, ICU etc)
Complete and document initial risk stratification/score
Develop and follow your protocol
Implement, monitor & document turning and positioning
Monitor, manage and document incontinence
Use good quality moist wound care
Document daily skin sheets on nurses notes
Document wounds completely in terms of size, depth,
drainage, slough/eschar, odor etc
Document wound treatments and changes in treatments
“Common sense is not so common” - Voltaire
40. FUTURE FOCUS AREAS
Nutritionassessment and management
Pain assessment and management
Proper choice of support surfaces
Prevention