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15Pressure Ulcer Treatment

Quick Reference Guideline Number 15

Created: .

Attention Clinicians

The Clinical Practice Guideline on which this Quick Reference Guide for Clinicians is based was developed by a multidisciplinary, private-sector panel comprising health care professionals and a consumer representative sponsored by the Agency for Health Care Policy and Research (AHCPR). Panel members were:

  • Nancy Bergstrom, PhD, RN, FAAN (Chair)
  • Richard M. Allman, MD
  • Oscar M. Alvarez, PhDM.
  • Alisan Bennett, EdD, RN
  • Carolyn E. Carlson, PhD, RN
  • Rita A. Frantz, PhD, RN, FAAN
  • Susan L. Garber, MA, OTR, FAOTA
  • Mitchell V. Kaminski, Jr., MD, SC, FACS, FICS, FACN
  • Mildred G. Kemp, PhD, RN, CETN, FAAN
  • Thomas A. Krouskop, PhD
  • Victor L. Lewis, Jr., MD, FACS
  • JoAnn Maklebust, MSN, RN, CS
  • David J. Margolis, MD, FACP
  • Elena M. Marvel, MSN, MA, RN
  • Steven I. Reger, PhD, CP
  • George T. Rodeheaver, PhD
  • Richard Salcido, MD, FAAPMR
  • George C. Xakellis, MD
  • Gary M. Yarkony, MD, FAAPMR

Consultants to the panel were Richard M. Allman, MD; Ronni Chernoff, PhD, RD; Sue Crow, MSN, RN; David C. Hadorn, MD; JoAnne Horsley, PhD, RN, FAAN; Henry Miller, PhD; Mary Susan O'Brien, PhD; George T. Rodeheaver, PhD; and Steven H. Woolf, MD, MPH.

An explicit, science-based methodology was employed along with expert clinical judgement to develop specific statements on patient assessment, treatment, and management of pressure ulcers. Extensive literature searches were conducted and critical reviews and syntheses were used to evaluate empirical evidence and significant outcomes. Peer review and pilot review were undertaken to evaluate the validity, reliability, and utility of the guideline in clinical practice.

This Quick Reference Guide for Clinicians presents summary points from the Clinical Practice Guideline. The latter provides a description of the guideline development process, thorough analysis and discussion of the available research, critical evaluation of the assumptions and knowledge of the field, more complete information for health care decisionmaking, consideration for patients with special needs, and references. Decisions to adopt particular recommendations from either publication must be made by practitioners in light of available resources and circumstances presented by the individual patient.

AHCPR invites comments and suggestions from users for consideration in development and updating of future guidelines. Please send written comments to: Director, Office of the Forum for Quality and Effectiveness in Health Care, AHCPR, Willco Building, Suite 310, 6000 Executive Boulevard, Rockville, MD 20852.

Abstract

This Quick Reference Guide for Clinicians contains highlights from the Clinical Practice Guideline version of Treatment of Pressure Ulcers, which was developed by a private-sector panel of health care providers and a consumer. Selected aspects of pressure ulcer assessment and treatment are presented. Topics covered include assessment of the patient and pressure ulcer(s), tissue load management, ulcer care, management of bacterial colonization and infection, operative repair of the pressure ulcer, and education and quality improvement. Algorithms are included to show the sequence of events related to the overall care of the individual with a pressure ulcer, nutritional assessment and support, management of tissue loads, ulcer care, and management of bacterial colonization and infection. Tables and forms are included as aids for selecting irrigation devices, cleansing solutions, support surfaces, and assessing the pressure ulcer and the patient's nutritional status.

Suggested Citation

This document is in the public domain and may be used and reprinted without special permission. AHCPR appreciates citation as to source, and the suggested format is provided below:Bergstrom N, Bennett MA, Carlson CE, et al. Pressure Ulcer Treatment.Clinical Practice Guideline. Quick Reference Guide for Clinicians, No. 15. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR Pub. No. 95-0653. Dec. 1994.

Purpose and Scope

Pressure ulcers are a serious problem that affects approximately 9 percent of all hospitalized patients and 23 percent of all nursing home patients. This condition can be difficult to treat and often results in pain, disfigurement, and prolonged hospitalization. However, prompt and effective treatment can minimize these deleterious effects and speed recovery.

A pressure ulcer is defined as any lesion caused by unrelieved pressure resulting in damage of underlying tissue. Pressure ulcers are usually located over bony prominences and are graded or staged to classify the degree of tissue damage observed; however, pressure ulcers do not necessarily progress from Stage I to Stage IV or heal from Stage IV to Stage I. The staging of pressure ulcers recommended for use here is consistent with the recommendations of the National Pressure Ulcer Advisory Panel Consensus Development Conference:

Stage I: Nonblanchable erythema of intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators.

Stage II: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.

Stage III: Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers.

These staging definitions recognize the following limitations:

  • Stage I ulcers may be superficial, or they may be a sign of deeper tissue damage.
  • Stage I pressure ulcers are not always reliably assessed, especially in patients with darkly pigmented skin.
  • When eschar is present, a pressure ulcer cannot be accurately staged until the eschar is removed.
  • It may be difficult to assess pressure ulcers in patients with casts, other orthopedic devices, or support stockings. Extra vigilance is required to assess ulcers under these circumstances.

This guide provides a comprehensive program for treating individuals with Stage II, III, and IV pressure ulcers. The recommendations are intended for clinicians who examine and treat persons who have pressure ulcers. These recommendations will be of interest to family physicians, internists, geriatricians, physiatrists, nurses and nurse practitioners, enterostomal therapists, infection control officers, physical and occupational therapists, psychological support staff, and dietitians in acute care, long-term care, rehabilitative, geriatric, and home settings. Although these recommendations are based on research involving adults, they may, at the clinician's discretion, be applied to children (but not to neonates).

Highlights of Patient Management

Effective pressure ulcer treatment is best achieved through a team approach involving patients, their families or caregivers, and health care providers. The clinician should:

  • Discuss pressure ulcer treatment options with patients and their families.
  • Encourage patients to be active participants in their care.
  • Develop an effective plan of care that is consistent with the patient's goals and wishes.

The recommended treatment program should focus on:

  • Assessment of the patient and the pressure ulcer(s).
  • Managing tissue loads.
  • Ulcer care.
  • Managing bacterial colonization and infection.
  • Operative repair of the pressure ulcer(s).
  • Education and quality improvement.

Figure 1 provides an overview of the activities related to pressure ulcer treatment. When applied to individual patients, this algorithm should be adapted to accommodate patient preferences and overall patient goals. Additional algorithms are provided throughout this quick reference guide to summarize approaches to nutritional assessment and support, management of tissue loads, ulcer care, and management of bacterial colonization and infection.

Figure 1 Treatment Activity Algorithm.

Figure

Figure 1 Treatment Activity Algorithm.

Assessment

Assessment is the starting point in preparing to treat or manage an individual with a pressure ulcer. Assessment involves the entire person, not just the ulcer, and is the basis for planning treatment and evaluating its effects. Adequate assessment is also essential for communication among caregivers. This section discusses recommendations for assessing the pressure ulcer and the individual.

Assessing the Pressure Ulcer

Initial assessment. Assess the pressure ulcer(s) initially for location, stage, size (length, width, and depth), sinus tracts, undermining, tunneling, exudate, necrotic tissue, and the presence or absence of granulation tissue and epithelialization. (See Figure 2 for a sample pressure ulcer assessment guide.)

Figure 2 Ulcer Assessment Guide.

Figure

Figure 2 Ulcer Assessment Guide.

Reassessment. Reassess pressure ulcers at least weekly (as shown in Figure 2). If the condition of the patient or wound deteriorates, reevaluate the treatment plan as soon as any evidence of deterioration is noted.

Monitoring progress. A clean pressure ulcer should show evidence of some healing within 2 to 4 weeks. If no progress can be demonstrated, reevaluate the adequacy of the overall treatment plan as well as adherence to this plan, making modifications as necessary.

Assessing the Individual

Assessment of the individual should address physical health, complications, nutritional assessment and management, pain assessment and management, and psychosocial assessment and management.

Physical Health and Complications

History and physical examination. Perform a complete history and physical examination, because a pressure ulcer should be assessed in the context of the patient's overall physical and psychosocial health.

Complications. Clinicians should be alert to the potential complications associated with pressure ulcers, such as amyloidosis, endocarditis, heterotopic bone formation, maggot infestation, meningitis, perineal-urethral fistula, pseudoaneurysm, septic arthritis, sinus tract or abscess, squamous cell carcinoma in the ulcer, and systemic complications of topical treatment (e.g., iodine toxicity and hearing loss after topical neomycin and systemic gentamicin). Three other complications--osteomyelitis, bacteremia, and advancing cellulitis--are discussed later in the recommendations for managing bacterial colonization and infection.

Nutritional Assessment and Management

Because many studies have linked pressure ulcers with malnutrition, screening for nutritional deficiencies is an important part of the initial assessment. The goal of nutritional assessment and management is to ensure that the diet of the individual with a pressure ulcer contains nutrients adequate to support healing. The following recommendations and the algorithm in Figure 3 are designed to help the clinician meet this goal.

Figure 3 Nutritional Assessment Support Algorithm.

Figure

Figure 3 Nutritional Assessment Support Algorithm.

Adequate dietary intake. Ensure adequate dietary intake to prevent malnutrition to the extent compatible with the individual's wishes.

Nutritional assessment. Perform an abbreviated nutritional assessment, as defined by the Nutritional Screening Initiative, at least every 3 months for individuals at risk for malnutrition. These include individuals who are unable to take food by mouth or who experience an involuntary change in weight. (See Figure 4 for a sample nutritional assessment guide.)

Figure 4 Nutritional Assessment Guide.

Figure

Figure 4 Nutritional Assessment Guide.

Nutritional support. Encourage dietary intake or supplementation if an individual with a pressure ulcer is malnourished. If dietary intake continues to be inadequate, impractical, or impossible, nutritional support (usually tube feeding) should be used to place the patient into positive nitrogen balance (approximately 30 to 35 calories/kg/day and 1.25 to 1.50 grams of protein/kg/day) according to the goals of care. As much as 2.00 grams of protein/kg/day may be needed.

Vitamin and mineral supplements. Give vitamin and mineral supplements if deficiencies are confirmed or suspected.

Pain Assessment and Management

The goal of pain management in the pressure ulcer patient is to eliminate the cause of the pain, to provide analgesia, or both. Additional information regarding pain assessment and management is provided in Acute Pain Management: Operative or Medical Procedures and Trauma. Clinical Practice Guideline, No. 1.

Assessment. Assess all patients for pain related to the pressure ulcer or its treatment. Caregivers should not assume that because a patient cannot express or respond to pain that it does not exist.

Management. Manage pain by eliminating or controlling the source of pain (e.g., covering wounds, adjusting support surfaces, repositioning). Because pain may be evoked or may be especially acute during dressing changes and debridement, the caregiver should try to prevent such discomfort or take steps to relieve it. Provide analgesia as needed and appropriate.

Psychosocial Assessment and Management

The goal of a psychosocial assessment is to gather the information necessary to formulate a plan of care consistent with individual and family preferences, goals, and abilities. The goal of psychosocial management is to create an environment conducive to patient adherence to the pressure ulcer treatment plan.

Assessment of the individual. All individuals being treated for pressure ulcers should undergo a psychosocial assessment to determine their ability and motivation to comprehend and adhere to the treatment program. The assessment should include but not be limited to mental status, learning ability, and depression; social support; polypharmacy (i.e., taking many drugs concurrently) or overmedication; alcohol and/or drug abuse; goals, values, and lifestyle; sexuality; culture and ethnicity; and stressors. Periodic reassessment is recommended.

Assessment of resources. Assess resources (e.g., availability and skill of caregivers, finances, equipment) of individuals being treated for pressure ulcers in the home.

Goal setting. Set treatment goals consistent with the values and lifestyle of the individual, family, and caregiver.

Interventions. Arrange interventions (e.g., psychological counseling, education) to meet identified psychosocial needs and goals. Followup should be planned in cooperation with the individual and the caregiver.

Managing Tissue Loads

The goal of tissue load management is to create an environment that enhances soft tissue viability and promotes healing of the pressure ulcer(s). The term "tissue load" refers to the distribution of pressure, friction, and shear on the tissue. The interventions are designed to decrease the magnitude of tissue load and provide levels of moisture and temperature that support tissue health and growth. Tissue load management can be achieved through the vigilant use of proper positioning techniques and support surfaces whether the individual is in bed or sitting in a chair. The algorithm in Figure 5 will help guide clinical decisions on the management of tissue loads.

Figure 5 Management of Tissue Loads Algorithm.

Figure

Figure 5 Management of Tissue Loads Algorithm.

While in Bed

Positioning techniques and support surfaces for patients in bed are important factors in the management of tissue loads.

Positioning Techniques

Staying off the ulcer. Avoid positioning patients on a pressure ulcer.

Positioning devices. Use positioning devices to raise a pressure ulcer off the support surface. If the patient is no longer at risk for developing pressure ulcers, these devices may reduce the need for pressure-reducing overlays, mattresses, and beds. Avoid using donut-type devices, which are more likely to cause pressure ulcers than to prevent them.

Written schedules. Establish a written repositioning schedule based on the patient's risk for additional ulcers and on the response of the tissue to pressure. Patients at higher risk of additional ulcers and those with a longer duration of reactive hyperemia should be turned more frequently. Written repositioning schedules should be developed even when patients are using pressure-reducing support surfaces, because these surfaces are only adjuncts to strategies for positioning and careful monitoring of at-risk patients.

Positioning at-risk patients. Assess all patients with existing pressure ulcers to determine their risk for developing additional pressure ulcers. For those individuals who remain at risk, institute the following measures recommended in Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guideline, No. 3:

  • Avoid positioning immobile individuals directly on their trochanters and use devices such as pillows and foam wedges that totally relieve pressure on the heels, most commonly by raising the heels off the bed.
  • Use positioning devices such as pillows or foam to prevent direct contact between bony prominences (such as knees or ankles).
  • Maintain the head of the bed at the lowest degree of elevation consistent with medical conditions and other restrictions. Limit the amount of time the head of the bed is elevated. The shear forces generated when an individual slides down in bed contribute to ischemia and necrosis of sacral tissue and undermining of existing sacral ulcers.

Support Surfaces

When one is selecting a support surface for a patient, the primary concern should be the therapeutic benefit associated with the product. A variety of support surfaces have been shown to provide an environment in which pressure ulcers improve, but there is no compelling evidence that one support surface consistently performs better than all others, under all circumstances. Therefore, the caregiver should consider a variety of factors when selecting a support surface, including the clinical condition of the patient, the characteristics of the care setting, and the characteristics of the support surface.

Table 1 categorizes the various classes of support surfaces according to their performance in counteracting the different forces that contribute to the development of pressure ulcers. After determining which of these forces might be increasing an individual's risk for pressure ulcers, the caregiver may find this table useful in selecting a support surface for a particular patient. In addition to considering the features listed in Table 1, caregivers also need to consider other performance factors, such as ease of use, requirements for maintenance, cost, and patient preference.

Table 1. Selected characteristics for classes of support surfaces.

Table

Table 1. Selected characteristics for classes of support surfaces.

It is important to remember that support surfaces are only one part of a comprehensive treatment plan. If an ulcer does not heal, the entire plan should be reevaluated before the support surface is changed.

The support surface should match the clinical condition and needs of the patient. The following patient characteristics should be considered when selecting a support surface:

Risk for additional ulcers. Assess all patients with existing pressure ulcers to determine their risk for developing additional pressure ulcers. If the patient remains at risk, use a pressure-reducing surface.

Indications for static support surfaces. Use a static support surface if a patient can assume a variety of positions without bearing weight on a pressure ulcer and without "bottoming out." The caregiver can determine whether the patient has bottomed out by placing an outstretched hand (palm up) under the overlay below the pressure ulcer or below the part of the body at risk for a pressure ulcer. If the caregiver feels less than an inch of support material, the patient has bottomed out and the support surface is inadequate.

Indications for dynamic support surfaces. Use a dynamic support surface if the patient cannot assume a variety of positions without bearing weight on a pressure ulcer, if the patient fully compresses the static support surface, or if the pressure ulcer does not show evidence of healing.

Indications for low-air-loss and air-fluidized beds. If a patient has large Stage III or Stage IV pressure ulcers on multiple turning surfaces, a low-air-loss bed or an air-fluidized bed may be indicated. A low-air-loss bed may also be indicated if the individual bottoms out or fails to heal on a dynamic overlay or mattress.

Need to control moisture. When excess moisture on intact skin is a potential source of maceration and skin breakdown, a support surface that provides airflow (e.g., air-fluidized and low-air-loss beds) can be important in drying the skin and preventing additional pressure ulcers. While lying on this type of support surface, patients should not wear incontinence briefs because the briefs obstruct airflow to the skin. Follow manufacturers' instructions for using linen and underpads.

While Sitting

Positioning techniques and support surfaces for patients who are sitting are important factors in the management of tissue loads.

Positioning Techniques

Avoiding pressure on the ulcer.A patient who has a pressure ulcer on a sitting surface should avoid sitting. If pressure on the ulcer can be relieved, limited sitting may be allowed.

Proper positioning. Consider postural alignment, distribution of weight, balance, stability, and pressure relief when positioning sitting individuals.

Frequent repositioning. Reposition the sitting individual so the points under pressure are shifted at least every hour. If this schedule cannot be kept or is inconsistent with overall treatment goals, return the patient to bed. Individuals who are able should be taught to shift their weight every 15 minutes.

Support Surfaces

Cushion selection. Select a cushion based on the specific needs of the individual who requires pressure reduction in a sitting position. Avoid donut-type devices, which are more likely to cause pressure ulcers than to prevent them.

Written plan. Develop a written plan for the use of positioning devices.

Ulcer Care

Initial care of the pressure ulcer involves debridement, wound cleansing, the application of dressings, and possibly adjunctive therapy. In some cases, operative repair will be required. In all cases, specific wound care strategies should be consistent with overall patient goals. Figure 6 offers a recommended management approach to ulcer care.

Figure 6 Management Approach to Ulcer Care.

Figure

Figure 6 Management Approach to Ulcer Care.

Debridement

Moist, devitalized tissue supports the growth of pathological organisms. Therefore, the removal of such tissue favorably alters the healing environment of a wound. Although debridement is a time- honored modality for treating pressure ulcers, it has not been studied in a randomized trial.

Removal of devitalized tissue. Remove devitalized tissue in pressure ulcers when appropriate for the patient's condition and consistent with patient goals.

Selection of a method. Select the method of debridement most appropriate to the patient's condition and goals.

  • Sharp, mechanical, enzymatic, and/or autolytic debridement techniques may be used when there is no urgent clinical need for drainage or removal of devitalized tissue.
  • Sharp debridement involves the use of a scalpel, scissor, or other sharp instrument to remove devitalized tissue. This method is the most rapid form of debridement and may be the most appropriate technique for removing areas of thick, adherent eschar and devitalized tissue in extensive ulcers.
  • If there is an urgent need for debridement, as with advancing cellulitis or sepsis, sharp debridement should be used.
  • Those performing sharp debridement should have demonstrated the necessary clinical skills and meet licensing requirements.
  • Although small wounds can be debrided at the bedside, extensive wounds are usually debrided in the operating room or in a special procedures room. When debriding extensive Stage IV ulcers in the operating room, the surgeon should consider a bone biopsy to detect osteomyelitis.
  • Mechanical debridement techniques include wet-to-dry dressings, hydrotherapy, wound irrigation, and dextranomers.
  • Enzymatic debridement is accomplished by applying topical debridement agents to devitalized tissue on the wound surface.
  • Autolytic debridement involves the use of synthetic dressings to cover a wound and allow devitalized tissue to self-digest from enzymes normally present in wound fluids. This technique should not be used if the wound is infected.

Dressings during and after debridement. Use clean, dry dressings for 8 to 24 hours after sharp debridement associated with bleeding; then reinstitute moist dressings. Clean dressings may also be used in conjunction with mechanical or enzymatic debridement techniques.

Stable heel ulcers, an exception. Heel ulcers with dry eschar need not be debrided if they do not have edema, erythema, fluctuance, or drainage. Assess these wounds daily to monitor for pressure ulcer complications that would require debridement (e.g., edema, erythema, fluctuance, drainage).

Pain. Prevent or manage pain associated with debridement as needed.

Wound Cleansing

Wound healing is optimized and the potential for infection is decreased when all necrotic tissue, exudate, and metabolic wastes are removed from the wound. The process of cleansing a wound involves selecting both a wound-cleansing solution and a mechanical means of delivering that solution to the wound. The benefits of obtaining a clean wound must be weighed against the potential trauma to the wound bed as a result of such cleansing. Routine wound cleansing should be accomplished with a minimum of chemical and mechanical trauma.

Cleansing. Cleanse wounds initially and at each dressing change.

Nontraumatic technique. Use minimal mechanical force and less coarse materials when cleansing the ulcer with gauze, cloth, or sponges.

Avoidance of antiseptics. Do not clean ulcer wounds with skin cleansers or antiseptic agents (e.g., povidone iodine, iodophor, sodium hypochlorite solution [Dakin's solution], hydrogen peroxide, acetic acid), because they are cytotoxic. Table 2 delineates a toxicity index by listing the dilutions required for various skin and wound cleansers to maintain the viability and phagocytic function of white blood cells exposed to these agents.

Table 2. Toxicity index for wound and skin cleansers.

Table

Table 2. Toxicity index for wound and skin cleansers.

Normal saline. Use normal saline for cleansing most pressure ulcers.

Appropriate irrigation pressures. Use enough irrigation pressure to enhance wound cleansing without causing trauma to the wound bed. Safe and effective ulcer irrigation pressures range from 4 to 15 pounds per square inch (psi). Irrigation pressures below 4 psi may not cleanse the wound adequately, and pressures greater than 15 psi may cause trauma and drive bacteria into the wound tissue. Irrigation devices that deliver 8 psi of pressure are significantly more effective in removing bacteria and preventing infection than is a bulb syringe. Table 3 indicates the irrigation pressure delivered by various clinically available devices.

Table 3. Irrigation pressures delivered by various devices.

Table

Table 3. Irrigation pressures delivered by various devices.

Whirlpool. Consider whirlpool treatment for cleansing pressure ulcers that contain thick exudate, slough, or necrotic tissue. Note that trauma can result if the wound is positioned too close to the high-pressure water jets. Discontinue whirlpool when the ulcer is clean.

Dressings

Pressure ulcers require dressings to maintain their physiologic integrity. An ideal dressing should protect the wound, be biocompatible, and provide ideal hydration. The condition of the ulcer bed and the desired dressing function determine the type of dressing needed. The cardinal rule is to keep the ulcer tissue moist and the surrounding intact skin dry.

Selection of a dressing. Use a dressing that will keep the ulcer bed continuously moist. (Wet-to-dry dressings should be used only for debridement and are not the same as continuously moist saline dressings, which keep the ulcer bed moist.) The following criteria should be considered when selecting a dressing:

  • Moist ulcer bed. Use clinical judgment to select a type of moist wound dressing suitable for the ulcer. Studies of different types of moist wound dressings showed no differences in pressure ulcer healing outcomes.
  • Dry surrounding skin. Choose a dressing that keeps the surrounding intact (periulcer) skin dry while keeping the ulcer bed moist.
  • Exudate control. Choose a dressing that controls exudate but does not desiccate the ulcer bed.Excessive exudate may delay wound healing and macerate surrounding tissue.
  • Caregiver time. Consider caregiver time when selecting a dressing. Film and hydrocolloid dressings require less caregiver time than do continuously moist saline gauze dressings.

Clinicians should also consider the following:

  • Prevent abscess formation. Eliminate wound dead space by loosely filling all cavities with dressing material. Avoid overpacking the wound. Overpacking may increase pressure and cause additional tissue damage.
  • Keep dressings intact. Monitor dressings applied near the anus, because they are difficult to keep intact. Taping the edges of dressings ("picture-framing") may reduce this problem.

Adjunctive Therapies

The roles of several adjunctive therapies in enhancing pressure ulcer healing have been investigated. The therapies considered by the panel included electrical stimulation; hyperbaric oxygen; infrared, ultraviolet, and low-energy laser irradiation; ultrasound; miscellaneous topical agents (e.g., sugar, vitamins, elements, hormones, cytokine growth factors, skin equivalents), and systemic drugs other than antibiotics (e.g., vasodilators, hemorrheologics, serotonin inhibitors, fibrolytic agents).

At this time, electrical stimulation is the only adjunctive therapy with sufficient supporting evidence to warrant recommendation by the panel. The panel recommends that clinicians consider a course of treatment with electrical stimulation for Stage III and IV pressure ulcers that have proved unresponsive to conventional therapy. Electrical stimulation may also be useful for recalcitrant Stage II ulcers.

To date, this therapy has been limited to a small number of research centers. Clinicians considering electrical stimulation therapy should ensure that they have proper equipment and trained personnel who are following protocols shown to be effective and safe in appropriately designed and properly conducted clinical trials.

Managing Bacterial Colonization and Infection

Stage II, III, and IV pressure ulcers are invariably colonized with bacteria. In most cases, adequate cleansing and debridement prevent bacterial colonization from proceeding to the point of clinical infection. Recommendations regarding the management of colonization and infection follow. Figure 7 guides the clinician through a preferred pathway for managing ulcer colonization and local and systemic infection.

Figure 7 Algorithm: Managing Ulcer Colonization and Local and Systemic Infection.

Figure

Figure 7 Algorithm: Managing Ulcer Colonization and Local and Systemic Infection.

Pressure Ulcer Colonization and Infection

Cleansing and debridement. Minimize pressure ulcer colonization and enhance wound healing by effective wound cleansing and debridement. If purulence or foul odor is present, more frequent cleansing and possibly debridement are required.

No swab cultures. Do not use swab cultures to diagnose wound infection because all pressure ulcers are colonized. Swab cultures detect only the surface colonization and may not truly reflect the organism(s) causing the tissue infection.

Topical antibiotic trial. Consider a 2-week trial of topical antibiotics for clean pressure ulcers that are not healing or are continuing to produce exudate after 2 to 4 weeks of optimal patient care (as defined in this guideline). The antibiotic should be effective against gram-negative, gram-positive, and anaerobic organisms (e.g., silver sulfadiazine, triple antibiotic). Monitor for allergic sensitization and other adverse reactions.

Diagnosis of soft tissue infection and osteomyelitis. Healing may be impaired if bacterial levels exceed 100,000 organisms per gram of tissue or if the patient has osteomyelitis. When the ulcer does not respond to topical antibiotic therapy, the clinician should perform quantitative bacterial cultures of the soft tissue and evaluate the patient for osteomyelitis.

  • Soft tissue infection. When cultures are required to diagnosis a soft tissue infection, the Centers for Disease Control and Prevention recommend obtaining fluid through needle aspiration or tissue through ulcer biopsy.
  • Osteomyelitis. Examination of a bone biopsy specimen is the "gold standard" for diagnosing osteomyelitis; however, this invasive diagnostic technique is not always appropriate. A combination of three tests (white blood cell count, erythrocyte sedimentation rate, and plain x-ray) has a positive predictive value of 68 percent when all three tests are positive.

No topical antiseptics. Do not use topical antiseptics (e.g., povidone iodine, iodophor, sodium hypochlorite [Dakin's solution], hydrogen peroxide, acetic acid) to reduce bacteria in wound tissue.

Systemic antibiotics for systemic infections. Institute appropriate systemic antibiotic therapy for patients with bacteremia, sepsis, advancing cellulitis, or osteomyelitis.

Urgent medical attention is required for patients with pressure ulcers who develop clinical signs of sepsis (e.g. unexplained fever, tachycardia, hypotension, deterioration in mental status). It is appropriate to rule out other causes of the symptoms, obtain blood cultures, and treat with antibiotics that will combat these organisms. Systemic antibiotics are not required for pressure ulcers with only clinical signs of local infection.

Prevention of contamination. Protect pressure ulcers from exogenous sources of contamination (e.g., feces).

Infection Control

The fear of cross-contamination of microorganisms within institutions is realistic. The following recommendations are provided to prevent cross-contamination of pathological organisms.

Body substance isolation. Follow body substance isolation (BSI) precautions or an equivalent system appropriate for the health care setting and the patient's condition when treating pressure ulcers.

Clean gloves. Use clean gloves for each patient. When treating multiple ulcers on the same patient, attend to the most contaminated ulcer last (e.g., in the perianal region). Remove gloves and wash hands between patients.

Sterile instruments for debridement. Use sterile (as opposed to clean) instruments to debride pressure ulcers. Following debridement, monitor the patient's temperature and be alert for signs of bacteremia or sepsis (e.g., unexplained fever, tachycardia, hypotension, deterioration in mental status).

Clean dressings. Use clean dressings, rather than sterile ones, to treat pressure ulcers in health care facilities, as long as dressing procedures comply with institutional infection-control guidelines. Clean dressings may also be used in the home setting. Disposal of contaminated dressings should be done in a manner consistent with local regulations.

Keeping dressings clean. Procedures to keep dressings clean and prevent cross-contamination should be established and rigorously adhered to. These procedures include the following:

  • Strict adherence to BSI and good handwashing between patients.
  • Multipatient treatment carts taken to the bedside should not be used to house dressing supplies. Individual patients should have their own dressing supplies that are protected from inadvertent environmental contamination by water damage, dust accumulation, or contact contaminants.
  • "Clean" bundled dressings can be purchased less expensively than can individual dressings; however, measures should be taken to ensure that they remain clean. Such measures include keeping dressings in the original package or in other plastic packaging; storing them in a clean, dry place; and discarding the entire package if any of the dressings become wet, contaminated, or dirty.
  • Caregivers must wash their hands before contact with the supply of clean dressings or dressing supplies. Prior to the dressing or treatment, only the number of dressings necessary for each dressing change should be removed from containers. Once the hands of the caregiver are soiled with wound secretions, they should not come in contact with the remaining clean dressings and other supplies until the gloves are removed and hands are washed. Dressings, instruments, and solutions should be obtained from suppliers who can ensure that shipment and handling will not expose the dressings and supplies to damage or contamination.

Disposal. Local regulations vary on the disposal of soiled dressings. The Environmental Protection Agency Recommends that soiled dressings be placed in securely fastened plastic bags before being added to other household trash.

Operative Repair of Pressure Ulcers

Operative procedures to repair pressure ulcers include one or more of the following: direct closure, skin grafting, skin flaps, musculocutaneous flaps, and free flaps. Although more research is needed to develop clear criteria for selecting those individuals most likely to benefit from surgical management, the panel has provided some general criteria. Preoperative patient counseling should include information about the operative procedures available and the anticipated benefits and potential risks of each. Factors that might impair healing should be addressed preoperatively. Vigilant postoperative followup is essential to healing and prevention of recurrence.

Patient Selection

Determine patient need and suitability for operative repair when clean Stage III or Stage IV pressure ulcers do not respond to optimal patient care (as defined in this guideline). Possible candidates are medically stable and adequately nourished and can tolerate operative blood loss and postoperative immobility. Quality of life, patient preferences, treatment goals, risk of recurrence, and expected rehabilitative outcome are additional considerations.

Controlling Factors That Impair Healing

Promote successful surgical closure by controlling or correcting factors that may be associated with impaired healing, such as smoking, spasticity, levels of bacterial colonization, incontinence, and urinary tract infection.

Selection of Methods

Use the most effective and least traumatic method to repair the ulcer defect. Wounds can be closed by direct closure, skin grafting, skin flaps, musculocutaneous flaps, and free flaps. To minimize recurrence, the choice of operative technique is based on the individual patient's needs and overall goals as well as on the specific site and extent of the ulcer.

Avoid Prophylactic Ischiectomy

Prophylactic ischiectomy is not recommended because it often results in perineal ulcers and urethral fistulas, which are more threatening problems than ischial ulcers.

Postoperative Care

Minimize pressure to the operative site by use of an air-fluidized bed, a low-air-loss bed, or a Stryker frame for a minimum of 2 weeks. Assess postoperative viability of the surgical site as clinically indicated. Have the patient slowly increase periods of time sitting or lying on the flap to increase its tolerance to pressure. To determine the degree of tolerance, monitor the flap for pallor, redness, or both that do not resolve after 10 minutes of pressure relief. Ongoing patient education is imperative to reduce the risk of recurrence.

Prevention of Recurrence

Assess for recurrence of pressure ulcers as an ongoing component of care. Caregivers should provide education and encourage adherence to measures for pressure reduction, daily skin examination, and intermittent relief techniques.

Education and Quality Improvement

Education

Institutions and agencies concerned with health care are responsible for developing and implementing educational programs designed to translate knowledge about pressure ulcers into effective treatment strategies. The goals of such programs are to promote the healing and prevent the deterioration of existing pressure ulcers and to prevent new ones. Education programs should include information on prevention and treatment, assessing tissue damage, and monitoring outcomes.

Prevention and Treatment: A Continuum

Program development and implementation. Design, develop, and implement educational programs for patients, caregivers, and health care providers that reflect a continuum of care. The program should begin with a structured, comprehensive, and organized approach to prevention and should culminate in effective treatment protocols that promote healing as well as prevent recurrence.

Target audience. Develop educational programs that target appropriate health care providers, patients, family members, and caregivers. Present information at an appropriate level for the target audience to maximize retention and ensure a carryover into practice. Use principles of adult learning (e.g., explanation, demonstration, questioning, group discussion, drills).

Patient/caregiver participation. Involve the patient and caregiver, when possible, in pressure ulcer treatment and prevention strategies and options. Include information on pain, discomfort, possible outcomes, and duration of treatment, if known. Encourage the patient to actively participate in and comply with decisions regarding pressure ulcer prevention and treatment.

Identification of protocol implementers. Educational programs should identify those responsible for pressure ulcer treatment and describe each person's role. The information presented and the degree of participation expected should be appropriate to the audience.

Assessing and Treating Tissue Damage

Emphasizing assessment. Educational programs should emphasize the need for accurate, consistent, and uniform assessment, description, and documentation of the extent of tissue damage.

Program content. Include the following information when developing an educational program on the treatment of pressure ulcers:

  • Etiology and pathology.
  • Risk factors.
  • Uniform terminology for stages of tissue damage based on specific classification.
  • Principles of wound healing.
  • Principles of nutritional support with regard to tissue integrity.
  • Individualized program of skin care.
  • Principles of cleansing and infection control.
  • Principles of postoperative care including positioning and support surfaces.
  • Principles of prevention to reduce recurrence.
  • Product selection (i.e., categories and uses of support surfaces, dressings, topical medications, or other agents).
  • Effects or influence of the physical and mechanical environment on the pressure ulcer, and strategies for management.
  • Mechanisms for accurate documentation and monitoring of pertinent data, including treatment interventions and healing progress.

Program revision. Update educational programs on an ongoing and regular basis to integrate new knowledge, techniques, or technologies.

Monitoring Outcomes

Effectiveness of educational programs. Evaluate the effectiveness of an educational program in terms of measurable outcomes: Implementation of guideline recommendations, healing of existing ulcers, reducing the incidence of new or recurrent ulcers, and preventing the deterioration of existing ulcers.

Identification of deficiencies. Include a structured, comprehensive, and organized educational program as an integral part of quality improvement monitoring. Use information from quality assurance/improvement surveys to identify deficiencies, evaluate the effectiveness of care, and determine the need for education and policy changes. Focus inservice training on identified deficiencies.

Quality Improvement

The goal of quality improvement is to develop and implement a systematic, interdisciplinary, and ongoing quality improvement program for facilitating comprehensive, consistent care that can be monitored, evaluated, and changed as patient conditions and current knowledge warrant. To develop and implement such a program, health care providers should:

  • Obtain intradepartmental and interdepartmental quality improvement support for pressure ulcer management as a major aspect of care.
  • Convene an interdisciplinary committee of interested and knowledgeable persons to address quality improvement in pressure ulcer management.
  • Identify and monitor the occurrence of pressure ulcers to determine their incidence and prevalence. This information will serve as a baseline to the development, implementation, and evaluation of treatment protocols.
  • Monitor the incidence and prevalence of pressure ulcers on a regular basis. To the extent possible, data should be collected concurrently rather than retrospectively.
  • Develop, implement, and evaluate educational programs based on the data obtained from quality improvement monitoring.

Selected Bibliography

  1. Acute Pain Management Guideline Panel. Acute pain management: operative or medical procedures and trauma. Clinical Practice Guideline, No. 1. Rockville (MD):US Department of Health and Human Services; Public Health Service; Agency for Health Care Policy and Research. 1992 Feb. AHCPR Publication No.: 92-0032. 145 p.
  2. Beltran KA, Thacker JG, Rodeheaver GT. Impact pressures generated by commercial wound irrigation devices. (Unpublished research report). Charlottesville (VA): University of Virginia Health Science Center; 1994.
  3. Environmental Protection Agency. Disposal tips for home health care. Washington (DC): US Government Printing Office; 1993 Nov. Report No.: EPA530-F-93-027 A. 8 p. Available from: RCRA Docket (5305), US Environmental Protection Agency, 401 M Street, SW, Washington, DC 20460.
  4. Foresman PA, Payne DS, Becker D, Lewis D, Rodeheaver GT. A relative toxicity index for wound cleansers. Wounds 1993;5(5):226-31.
  5. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988 Jun;16(3):128-40. [See Erratum in Am J Infect Control 1988 Aug;16(4):177.] [PubMed: 2841893]
  6. Kemp MG, Krouskop TA. Pressure ulcers: Reducing the incidence and severity by managing pressure. J Gerontol Nurs 1994;20(9):27-34. [PubMed: 7930395]
  7. Lynch P, Jackson MM, Cummings MJ, Stamm WE. Rethinking the role of isolation practices in the prevention of nosocomial infections. Ann Intern Med 1987 Aug;107(2):243-6. [PubMed: 3605901]
  8. Lynch P, Cummings MJ, Roberts PL, Herriott MJ, Yates B, Stamm WE. Implementing and evaluating a system of generic infection precautions: body substance isolation. Am J Infect Control 1990 Feb;18(1):1-12. [PubMed: 2156467]
  9. National Pressure Ulcer Advisory Panel (NPUAP). Pressure ulcers prevalence, cost and risk assessment: consensus development conference statement. Decubitus 1989 May;2(2):24-8. [PubMed: 2665781]
  10. Greer, Margolis, Mitchell, Grunwald & Associates. Nutrition screening manual for professionals caring for older Americans: nutrition screening initiative. Washington DC: Greer, Margolis, Mitchell, Grunwald & Associates; 1991. 24 pp. Available from: The Nutrition Screening Initiative, 2626 Pennsylvania Avenue, NW, Suite 301, Washington, DC 20037.
  11. Panel for the Prediction and Prevention of Pressure Ulcers in Adults. Pressure ulcers in adults: prediction and prevention. Clinical Practice Guideline, No. 3. Rockville (MD): US Department of Health and Human Services; Public Health Service; Agency for Health Care Policy and Research. 1992 May. AHCPR Publication No.: 92-0047. 63 p.
  12. Rutala WA. APIC guideline for selection and use of disinfectants. Am J Infect Control 1990 Apr;18(2):99-117. U.S. Department of Health and Human Services Public Health Service Agency for Health Care Policy and Research Executive Office Center, Suite 501 2101 East Jefferson Street Rockville, MD 20852 AHCPR Publication No. 95-0653 December 1994.

AHCPR Publication No. 95-0653.

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