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6/29/2016
1
Clinical Practice Guidelines:
Wound Dressings for the
Management of Pressure
Injuries
Margaret Goldberg, MSN, RN, CWOCN
June 29, 2016
npuap.org
NPUAP MissionThe National Pressure Ulcer
Advisory Panel (NPUAP)
serves as the authoritative
voice for improved patient
outcomes in pressure injury
prevention and treatment
through public policy,
education and research.
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
2
International Guideline
NPUAP – in collaboration with the
European Pressure Ulcer Advisory
Panel (EPUAP) and the Pan Pacific
Pressure Injury Alliance (PPPIA) –
has worked to develop a NEW
pressure ulcer prevention and
treatment Clinical Practice
Guideline and a companion Quick
Reference Guide.
Purchase your copy today at
www.npuap.org
npuap.org©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
NPUAP Monograph
Released in November 2012, the 254-page,
24 chapter monograph, Pressure Ulcers:
Prevalence, Incidence and Implications for the
Future was authored by 27 experts from NPUAP
and invited authorities and edited by NPUAP
Alumna Dr. Barbara Pieper.
The monograph focuses on pressure ulcer rates
from all clinical settings and populations; rates in
special populations; a review of pressure ulcer
prevention programs; and a discussion of the
state of pressure ulcers in America over the last
decade.
Purchase the monograph today at www.npuap.org
• E-version $49
• Individual Chapters $19npuap.org
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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Save the date
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Save the date
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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25 – 29 September
www.wuwhs2016.com
THANK YOU to the following companies that have provided support for this webinar!
American Medical Technologies
ArjoHuntleigh
Augustana Care
ConvaTec
EHOB, Inc.
First Quality Healthcare
Hill-Rom
Joerns Healthcare
Leaf Healthcare
Medline Industries
Mölnlycke Health Care
Span America
Tamarack Habilitation Technologies
WellsenseThe NPUAP webinar commercial supporters did not
have any input regarding the content of this
presentation.
6/29/2016
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Faculty Disclosure
The following faculty member has listed a financial
interest/arrangement with one or more of the corporate
organizations listed below, however no conflict of
interests exists for this webinar.
• Margaret Goldberg, MSN, RN, CWOCN
Member of the Nursing Advisory Panel for Acelity.
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Planning Committee Disclosures
• Sharon Baranoski, MSN, RN, CWCN, APN-CCNS, FAAN
• Joyce Black, PhD, RN, CWCN, FAAN
• Jeffrey Levine, MD
• Mary Litchford, PhD, RD, LDN
• Sally O’Neill, PhD
• Mary Sieggreen, MSN, CNS, NP, CVN
The planning committee members have listed no financial interest/arrangements that would be considered a conflict of interest.
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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Objective
Describe criteria for wound dressing
selection from the clinical practice
guidelines
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Strengths of Evidence - The body of evidence supporting each recommendation was given a level of evidence
A. The recommendation supported by direct scientific evidence controlled trials on pressure ulcers in humans (level 1 studies)
B. Supported by direct scientific evidence from clinical series on pressure ulcers in humans
(level 2, 3, 4, 5 studies)
C. Supported by indirect evidence (e.g. studies in healthy humans, humans with other types of chronic wounds, animal models) and/or expert opinion
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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Introduction to wound dressings for treatment of pressure ulcers
Wound dressings are a central
component of pressure ulcer care
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Since the 1960’s, it has been accepted that wound
healing is optimized when the wound is kept in
a moist environment rather than
– air-dried (OTA)
– dried with heat lamps
– treating with topically applied drying agents
Dressings for Pressure Ulcers
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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Dressings
Occlusive or semi-occlusive
wound dressings that maintain
wound bed moisture promote
re-epithelialization and wound
closure
Wound dressings for pressure
ulcers are designed to:
• Improve wound healing time
• Absorb blood and tissue exudate
• Minimize pain associated with
application and removal
• Absorb and control malodour
• Reduce injury to periwound skin
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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General Recommendations
Wound dressing selection is based on the:
– Ability to keep the wound bed moist
– Need to address bacterial bioburden
– Nature/volume of wound drainage
– Condition of the tissue in the ulcer bed
– Condition of peri-ulcer skin
– Ulcer size, depth and location
– Presence of tunneling and/or undermining
– Goals of the individual with the ulcer
SOE = C©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
General Recommendations
A clean granulating pressure ulcer requires a dressing that
remains in contact with the wound bed or a skin barrier that
keeps the periwound dry and prevents maceration.
As the ulcer either heals or deteriorates over time, the type of
wound dressing most appropriate for promotion of healing may
change.
For example wound exudate usually decreases as the pressure
ulcer heals.
This statement is based on expert opinion
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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Protect peri-ulcer skin
(SOE = C)
General Recommendations
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
General Recommendations
Assess pressure ulcers at
every wound dressing
change and confirm the
appropriateness of the
current dressing regimen.
SOE = C
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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General Recommendations
(SOE = C)
Follow manufacturer
recommendations,
especially related to
frequency of dressing
change
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Change dressing if feces seep
beneath the dressing
(SOE = C)
General Recommendations
6/29/2016
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General Recommendations
The plan of care should
guide usual dressing wear
times and contain
provisionary plans for
dressings changes if needed
(for family, individual and
staff) due to soiling,
loosening, etc. (SOC = C)
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
General Recommendations
Ensure dressing material
completely removed with each
dressing change
(SOE = C)
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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Hydrocolloid Dressings
• Use for clean Stage 2 pressure ulcers in
body areas where they will not roll or
melt. (SOE = B)
• Consider use for noninfected, shallow
Stage 3 pressure ulcers.
(SOE = B)
• Consider using filler dressings beneath
hydrocolloid dressings in deep ulcers to
fill in dead space.
(SOE = B)
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Hydrocolloid Dressings
HCPC Codes A6234 –A6241
For use on wounds with light to moderate exudate.
Usual dressing change for covers or fillers, is up to 3
times per week.
Remove carefully on fragile skin to reduce
skin trauma
(SOE = B)
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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Transparent Film Dressings
• Consider using for autolytic debridement
when the individual is not
immunocompromised. (SOE = C)
• Consider using as a secondary dressing for
pressure ulcers treated with alginates or
other wound filler that will likely remain in
the ulcer bed for an extended period of time
(e.g., 3-5 days).
(SOE = C)
• Carefully remove film dressings on fragile
skin to reduce skin trauma. (SOE = C)
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Transparent Film Dressings (cont.)
Do not use as the tissue interface layer over moderately to heavily exudating ulcers. (SOE = C)
Do not use as the cover dressing over enzymatic debriding agents, gels or ointments. (SOE = C)
HCPC A6257-A6259
Covered when used on open partial thickness wounds
with minimal exudate or closed wounds.
Usual dressing change is up to 3 times per week.
6/29/2016
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Hydrogel Dressings
Consider use on shallow, minimally
exudating pressure ulcers.
(SOE = B)
Consider the use of amorphous hydrogel for
pressure ulcers that are not clinically infected
and are granulating. (SOE = B)
Consider use for treatment of dry ulcer beds
(SOE = C)
Consider use for painful pressure ulcers.
(SOE = C)©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Hydrogel Dressings (Cont.)
Consider the use of hydrogel sheet dressings for
pressure ulcers without depth and contours and/or
on body areas that are at risk for dressing
migration. (SOE = C)
Consider the use of amorphous hydrogel for
pressure ulcers with depth and contours and/or on
body areas that are not at risk for dressing
migration. (SOE = C)
HCPC A6231-A6233 – A6242-A6248 Pads, Ribbons
Used on full thickness wounds with minimal or no exudate (e.g.,
stage 3 or 4 ulcers).Usual dressing change for hydrogel wound cover
without adhesive border or hydrogel wound fillers is up to once per
day.©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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Alginate Dressings
Consider for the treatment of moderately and heavily exudating ulcers. (SOE = B)
Consider in clinically infected ulcers when there is appropriate concurrent treatment of infection. (SOE = C)
Gently remove the alginate dressing, irrigating it first to ease removal if necessary.
(SOE = C)
Consider lengthening the interval or changing the type of dressing if the alginate dressing is still dry at the scheduled time for dressing change. SOE = C)©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Alginate Dressings
HCPC A6196-A6199 - Alginate or other fiber
gelling dressing
For moderately to highly exudative full
thickness (e.g., stage 3 or 4 ulcers): and
alginate or other fiber gelling dressing
fillers for moderately exudative full
thickness wound cavities (e.g., stage 3 or
4 ulcers).
Not medically necessary for dry wounds or
covered with eschar. Change once per day.
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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Foam Dressings
Consider using on exudative Stage 2 and shallow stage 3 pressure ulcers. (SOE = B)
Avoid using single small pieces of foam in exudating cavity ulcers. (SOE = C)
Consider using gelling foam in highly exuding pressure ulcers. (SOE = C)
HCPC A6209-A6215 Foam Dressings
Used on full thickness wounds (e.g., stage 3 or 4
ulcers) with moderate to heavy exudate.
Dressing change up to 3 times week. Foam wound
fillers up to once per day.©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Silver-Impregnated Dressings
Consider use for pressure ulcers that are
clinically infected or heavily colonized.
(SOE =B)
Use for ulcers at high risk of infection.
(SOE =B)
Avoid prolonged use, discontinue when
wound infection is controlled.
(SOE = C)
HCPC 4649 – Surgical Supply Misc.©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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Honey-Impregnated Dressings
Consider use of dressings impregnated with medical-grade honey for the treatment of Stage 2 and 3 pressure ulcers. (SOE = C)
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Cadexomer Iodine Dressings
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HCPC A6261-Gel HCPC A6262-Pad
Reduces bacterial load. Once daily dressing change.
Consider use in moderately to highly
exudating pressure ulcers. (SOE = C)
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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Gauze Dressing
37
Avoid using for open pressure ulcers that have
been cleansed and debrided because they are
labor-intensive, cause pain when removed if dry,
and lead to desiccation of viable tissue if they dry.
(SOE = C)
When other forms of moisture-retentive dressings
are not available, continually moist gauze is
preferable to dry gauze.
(SOE = C)
Use as a cover dressing to reduce evaporation
when the tissue interface layuer is moist.
(SOE= C)
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Gauze Dressing
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Use loosely woven gauze for highly
exuding ulcers: tightly woven gauze used
for minimally exuding ulcers. SOE = C
Loosely fill (rather than tightly pack) ulcers
with large tissue defects and dead space
with saline-moistened gauze when
moisture retentive dressing are not
available SOE = C
Change gauze often enough to manage
exudate SOE = C
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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Gauze Dressing
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Use a single gauze strip to fill deep ulcers;
Do not use multiple gauze dressings, because
retained gauze in the ulcer bed can serve as a
source of infection. (SOE = C)
Consider using impregnated forms of gauze to
prevent evaporation of moisture from continuously
moist gauze dressing. (SOE = C)
Gauze non-impregnated A6216-A6221, A6402-6404,A6407
Gauze, impregnated w/other than water, normal saline,
hydrogel or zinc paste A6222-A6224, A6266
Gauze impregnated water or normal saline A6228-A6230)
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Silicone Dressings
Consider using as a wound contact layer to promote atraumatic dressing changes.
(SOE = B)
Consider using to prevent periwound tissue injury when periwound tissue is fragile or friable.
(SOE = B)
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HCPC A6025 Gel Sheet
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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Collagen Matrix Dressings
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Consider use for non-healing Stage 3 and 4
pressure ulcers. (SOE = C)
HCPC A6010-Collagen based wound filler,
dry form
A6011 Collagen based wound filler
gel/paste
A6021-A6024 Sterile sheet may be used as
a primary or secondary dressing.
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Composite Dressings
Many of the dressing types listed here are manufactured in combinations.
Various composite dressings with new components for specific purposes emerge in the wound dressing market.
42 ©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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Biological Dressings
Biologicals function as protective wound cover and may be cellular (contain living cells) or acellular (bioglogically inert).
Due to insufficient evidence to support or refute the use of biological dressings in the treatment of pressure ulcers, biological dressings are not recommended for routine use at this time. SOE= C
43 ©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Growth Factors: Recombinant Platelet-Derived Growth Factor
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Consider using Platelet-Derived Growth
Factors for treatment of stage 3 and 4
pressure ulcers that have delayed healing.
SOE = B
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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Growth Factors: Other growth factors
45
Due to insufficient evidence to support or
refute the use of growth factors (other
than recombinant platelet-derived growth
factor) in the treatment of pressure ulcers
they are not recommended for routine use
at this time.
SOE = C
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Prophylactic Dressings
Emerging evidence supports a role of
prophylactic dressing in decreasing friction
and reducing localized shear forces.
Consider applying a polyurethane foam
dressing to bony prominences (e.g., heels,
sacrum) for the prevention of pressure
ulcers in anatomical areas frequently
subjected to friction and shear. SOE = B
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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Prophylactic Dressings
When selecting a prophylactic dressing
consider:
• Ability of the dressing to manage
microclimate
• Ease of application and removal
• Ability to regularly assess the skin
• Anatomical location where the dressing
will be applied
• The correct dressing size SOE = C
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Prophylactic Dressings
Continue to use all other preventative
measure necessary when using prophylactic
dressings SOE = C
Assess the skin for signs of pressure ulcer
development at each dressing change or at
least daily, confirm appropriateness of
current regiment SOE= C
Replace the dressing if damaged, displaced
loosened or excessively moist. SOE = C©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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Negative Pressure Wound Therapy (NPWT)
NPWT used as wound treatment modality for
decades
Used as late treatment for recalcitrant
wounds
Now being used as a first line treatment
More research is needed to identify which
participants are most likely to benefit from NPWT
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Negative Pressure Wound Therapy (NPWT)
NPWT has greatest efficacy in reducing wound
volume
Serves as an adjuvant therapy when combined with
debridement and other treatments that promote
wound healing such as nutritional support and
pressure redistribution.
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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Negative Pressure Wound Therapy (NPWT)
1. Consider as an early adjuvant for the treatment
of deep Stage 3 or 4 pressure ulcers SOE B
2. Debride Pressure Ulcer of necrotic tissue prior to
NPWT SOE = C
3. Follow a safe regimen in applying and removing
NPWT system SOE = C
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
Negative Pressure Wound Therapy (NPWT)
4. Evaluate the pressure ulcer with each dressing
change
5. If pain is anticipated consider:
nonadherent interface dressing
lowering the level of pressure, change type of
pressure
use moist gauze filler instead of foam
6. Educate the individual and caregivers about
NPWT when used in the community setting
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
6/29/2016
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Apply Evidence to Practice
Be sure to carefully read dressing
package inserts to ensure
appropriate interventions
It is every clinician’s responsibility
to educate other healthcare
providers and to provide
references for their consideration
Contemporary practice should
always incorporate evolving
evidence
Inspire change in your practice setting!
53
©2016 National Pressure Ulcer Advisory Panel | www.npuap.org
CEU Test Information
To earn the 1.0 continuing education credit
from today’s webinar please visit the link
below.
This information will also be emailed out to
participants ONE HOUR after the conclusion
of the webinar.
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