pressure ulcers for physicians

8/7/2019 Pressure Ulcers for Physicians

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Wound Care for PhysiciansWound Care for Physicians

Assessment, DocumentationAssessment, Documentationand Treatmentand Treatment

Rebecca Roberts RN MSN CWOCNRebecca Roberts RN MSN CWOCN

Gayle MooreGayle Moore--Lisa RN MSN CWOCNLisa RN MSN CWOCNGarth Ireland RN MSN MPA CWOCNGarth Ireland RN MSN MPA CWOCN


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ObjectivesObjectives

By the end of the presentation theBy the end of the presentation theparticipant will be able toparticipant will be able to

accurately assess and document patientaccurately assess and document patientwoundswounds

list basic wound care principleslist basic wound care principles

identify wound care products available atidentify wound care products available atUHCMSUHCMS


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AssessmentWound Measurement

Length: head to footWidth: perpendicularto lengthDepthUndermining:Clock

faceTunnel: tract in thewound


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AssessmentAssessment

Wound measurementWound measurement Wound drawingWound drawing

PhotographyPhotography


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Wound AssessmentWound Assessment

Wound bed:Wound bed: Color: red, black (eschar), yellow (slough)Color: red, black (eschar), yellow (slough)

Exudate:Exudate: ColorColor

OdorOdor

QuantityQuantity

Periwound skinPeriwound skin Erythma, Maceration, denudedErythma, Maceration, denuded

Palpate for induration, warmth, fluctuationPalpate for induration, warmth, fluctuation


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Wound TypesWound Types Pressure UlcersPressure Ulcers

Tissue damage due to pressureTissue damage due to pressure

Staged 1 to 4 based on depth of tissue involvedStaged 1 to 4 based on depth of tissue involved Only staged if wound bed visible otherwise unstageableOnly staged if wound bed visible otherwise unstageable

or deep tissue injuryor deep tissue injury

Usually over pressure pointsUsually over pressure points OcciputOcciput

ElbowElbow

ScapulaScapula

SacrumSacrum

IschiumIschium

MalleolusMalleolus

HipHip

Braces, casts or tubingBraces, casts or tubing


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Pressure Ulcer DefinitionPressure Ulcer Definition

A pressure ulcer is a localized injury toA pressure ulcer is a localized injury to

skin and/or underlying tissue usually overskin and/or underlying tissue usually overa bony prominence a result of pressure, ora bony prominence a result of pressure, orpressure in combination with shear and/orpressure in combination with shear and/or

friction.friction.


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Pressure Ulcer StagingPressure Ulcer Staging

The National Pressure Ulcer AdvisoryThe National Pressure Ulcer Advisory

Panel has divided pressure ulcers intoPanel has divided pressure ulcers into4 stages based on anatomical tissue4 stages based on anatomical tissueloss and has included two additionalloss and has included two additional

categories of suspected deep tissuecategories of suspected deep tissueinjury and unstageable pressureinjury and unstageable pressure

ulcers.ulcers.


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UHCMC FocusUHCMC Focus

University Hospital Case Medical Center isUniversity Hospital Case Medical Center is

committed to the prevention of allcommitted to the prevention of allnosocomial pressure ulcers. The goal isnosocomial pressure ulcers. The goal is

zero incidence of pressure ulcers acquiredzero incidence of pressure ulcers acquired

during hospitalization.during hospitalization.


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Physician RolePhysician Role

CMS is asking that a pressure ulcer beCMS is asking that a pressure ulcer beproperly documented by the physicianproperly documented by the physician

upon admission. A pressure ulcerupon admission. A pressure ulcerdocumented by the physician after thedocumented by the physician after the

admission will be counted as aadmission will be counted as a

nosocomial pressure ulcer. This isnosocomial pressure ulcer. This iseven if there is admissioneven if there is admission

documentation in the chart by otherdocumentation in the chart by otherservices such as nursing or dietaryservices such as nursing or dietary

that the ulcer existed.that the ulcer existed.


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Physician RolePhysician Role

For the admission assessment theFor the admission assessment thephysician must view the patient from headphysician must view the patient from headto toe. Dressings must be removed, ifto toe. Dressings must be removed, if

possible, and the patient turned to viewpossible, and the patient turned to viewpressure points such as the heels, sacrum,pressure points such as the heels, sacrum,occiput , elbows and scapulaocciput , elbows and scapula

Pressure ulcers present on admission needPressure ulcers present on admission needto be documented as such and properlyto be documented as such and properlystaged in the record.staged in the record.


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Why at This Time?Why at This Time?

The Center for Medicare and MedicaidThe Center for Medicare and MedicaidService (CMS) has stated that effectiveService (CMS) has stated that effectiveOctober 1, 2008, hospitals will not be paidOctober 1, 2008, hospitals will not be paidfor the care of nosocomial pressure ulcers.for the care of nosocomial pressure ulcers.

Since many private insurances followSince many private insurances followMedicare guidelines, these private plansMedicare guidelines, these private plans

may also institute similar restrictions.may also institute similar restrictions.


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Current HospitalCurrent Hospital

InitiativesInitiatives Recent replacement of all patient bedsRecent replacement of all patient beds

with pressure reduction surfaces onwith pressure reduction surfaces on

Medical surgical floors.Medical surgical floors.

Evaluation of replacement beds forEvaluation of replacement beds forintensive care units and operatingintensive care units and operating

suites.suites. Extensive nursing inExtensive nursing in--service onservice on

assessment, prevention and treatmentassessment, prevention and treatment

of pressure related skin problems.of pressure related skin problems.


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Stage IStage I

Intact skin with nonIntact skin with non--blanchable redness of ablanchable redness of alocalized area usually over alocalized area usually over a

bony prominence.bony prominence. Pigmented skin may notPigmented skin may not

have visable blanching. Itshave visable blanching. Itscolor may be different fromcolor may be different fromthe surrounding area.the surrounding area.

The area may be painful,The area may be painful,firm, soft, warmer or coolerfirm, soft, warmer or coolerthan adjacent tissue.than adjacent tissue.


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Stage IStage I


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Stage IStage I


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Stage IIStage II

Partial thickness loss of dermis presentingPartial thickness loss of dermis presentingas a shallow open ulcer with a red or pinkas a shallow open ulcer with a red or pink

wound bed. May also present as an intactwound bed. May also present as an intactor open/ruptured serumor open/ruptured serum--filled blister.filled blister.

A shiny or dry shallow ulcer without sloughA shiny or dry shallow ulcer without sloughor bruising (indicative of suspected deepor bruising (indicative of suspected deep

tissue injury).tissue injury).

Does not include: skin tears, tape burns,Does not include: skin tears, tape burns,perineal dermatitis, maceration orperineal dermatitis, maceration orexcoriation.excoriation.


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Stage II Pressure UlcersStage II Pressure Ulcers


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Stage IIIStage III

Full thickness tissue loss.Full thickness tissue loss.Subcutaneous fat may be visible butSubcutaneous fat may be visible but

not bone, tendon or muscle are notnot bone, tendon or muscle are notexposed.exposed.

The depth of a stage III pressureThe depth of a stage III pressure

varies by anatomical location. Thevaries by anatomical location. Thebridge of the nose, occiput andbridge of the nose, occiput andmalleolus do not have subcutaneousmalleolus do not have subcutaneous

tissue and stage III ulcer can betissue and stage III ulcer can be


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Stage III Pressure UlcerStage III Pressure Ulcer


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Stage IVStage IV

Full thickness tissue loss with exposedFull thickness tissue loss with exposedbone, tendon and/or muscle.bone, tendon and/or muscle.

Slough or eschar may be present inSlough or eschar may be present insome parts of the wound.some parts of the wound.

Often includes undermining orOften includes undermining or

tunneling.tunneling.


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Stage IV Pressure UlcerStage IV Pressure Ulcer


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Unstageable PressureUnstageable Pressure

UlcerUlcer Full thickness tissue loss in which the baseFull thickness tissue loss in which the base

of the ulcer is covered by slough (yellow,of the ulcer is covered by slough (yellow,

tan, brown) and/or eschar (tan, brown ortan, brown) and/or eschar (tan, brown orblack) in the wound bed.black) in the wound bed.

Until enough slough and/or eschar isUntil enough slough and/or eschar isremoved to expose the base of the wound,removed to expose the base of the wound,the true depth and therefore stage can notthe true depth and therefore stage can notbe determined.be determined.

Stable (dry, adherent, intact withoutStable (dry, adherent, intact withouterythema or fluctuance) eschar on the heelserythema or fluctuance) eschar on the heelsserves as the bodys natural cover andserves as the bodys natural cover andshould not be removed.should not be removed.


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UlcerUlcer


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UlcerUlcer


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UlcerUlcer


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Suspected Deep TissueSuspected Deep Tissue

InjuryInjury Purple or maroon localized areaPurple or maroon localized area

discolored intact skin or blooddiscolored intact skin or blood--filledfilled

blister due to damage of underlyingblister due to damage of underlyingsoft tissue from pressure and/or shearsoft tissue from pressure and/or shear

The area may be preceded by tissueThe area may be preceded by tissuethat is firm, mushy, boggy, warmer orthat is firm, mushy, boggy, warmer orcooler as compared to adjacent tissue.cooler as compared to adjacent tissue.

The area may evolve rapidly to exposeThe area may evolve rapidly to exposeadditional layers of tissue injury.additional layers of tissue injury.


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Suspected Deep TissueSuspected Deep Tissue

InjuryInjury


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Pressure vs. VascularPressure vs. Vascular

It is important to distinguish betweenIt is important to distinguish betweenpressure and possible vascular causespressure and possible vascular causes

of tissue injury.of tissue injury.

Pressure related injuries occur overPressure related injuries occur overbony prominences or areas ofbony prominences or areas of

shearing. Pressure injury can also beshearing. Pressure injury can also berelated to equipment such as braces,related to equipment such as braces,casts and tubing.casts and tubing.


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Venous UlcersVenous Ulcers

Medial lower legMedial lower leg

Champagne GlassChampagne Glass

legleg Dependent edemaDependent edema

HemosiderinHemosiderinstainingstaining

Weeping woundWeeping woundwith irregularwith irregularbordersborders


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Venous UlcersVenous Ulcers


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Arterial UlcersArterial Ulcers

Cold, hairless legCold, hairless leg

Lack of pulseLack of pulse

Pain on elevationPain on elevation Relief on dependentRelief on dependent

positionposition

Wound with punchedWound with punched

out appearance andout appearance andpale or necroticpale or necroticwound bedwound bed


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Arterial UlcersArterial Ulcers


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Neuropathic/DiabeticNeuropathic/Diabetic

UlcerUlcer Plantar surface of the footPlantar surface of the foot

Round wound surrounded by callasRound wound surrounded by callas

Lack of sensationLack of sensation

Foot deformity: Charcot foot.Foot deformity: Charcot foot.


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Surgical WoundsSurgical Wounds

DehiscenceDehiscence

InfectionInfection

FistulaFistula

NecrosisNecrosis

Altered wound healingAltered wound healing


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Principles of WoundPrinciples of Wound

HealingHealingProtect wound and provideProtect wound and provide

a moist wounda moist woundenvironmentenvironment Cover woundCover wound

Fill in wound cavity

Fill in wound cavity

Moisten dry woundsMoisten dry wounds

Control excessive moistureControl excessive moisture


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Protect and ManageProtect and Manage

MoistureMoisture Wet to Moist NOT Wet to DryWet to Moist NOT Wet to Dry

New post operative wounds to monitorNew post operative wounds to monitor

bleedingbleeding

Twice a day dressing changes thatTwice a day dressing changes thatincrease risk of contaminationincrease risk of contamination

Can reduce frequency of dressing changeCan reduce frequency of dressing changeby adding moisture (Duoderm Hydrogel)by adding moisture (Duoderm Hydrogel)

PainfulPainful


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MoistureMoisture Mepilex Border DressingsMepilex Border Dressings

Silicone dressing of various sizesSilicone dressing of various sizes

Non occlusive to allow for air flowNon occlusive to allow for air flow

Reduces pain and further trauma whenReduces pain and further trauma whenremovedremoved

Change every 3 to 5 daysChange every 3 to 5 days For stage I and II PU, skin tears or forFor stage I and II PU, skin tears or for

cover dressings.cover dressings.


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MoistureMoisture Xenaderm OintmentXenaderm Ointment

Protective barrier to skinProtective barrier to skin

Perineal DermatitisPerineal Dermatitis

Skin TearsSkin Tears

Radiation DermatitisRadiation Dermatitis

Requires MD orderRequires MD order Apply once to twice a day and afterApply once to twice a day and after

incontinenceincontinence


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MoistureMoisture Hydrocolloid (Duoderm)Hydrocolloid (Duoderm)

Wound cover and protectionWound cover and protection

Occlusive for minimal exudateOcclusive for minimal exudate

Change 2 to 3 times per weekChange 2 to 3 times per week

Used in home care to reduce visitsUsed in home care to reduce visits

Can cause trauma to area when removedCan cause trauma to area when removed


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MoistureMoisture Mepilex Transfer DressingMepilex Transfer Dressing

For heavily draining wounds such asFor heavily draining wounds such as

weeping venous wound or bullous lesionsweeping venous wound or bullous lesions

Silicone foam dressingSilicone foam dressing

Easy to remove with little trauma toEasy to remove with little trauma to

tissuetissue Wicks drainage. Requires absorbentWicks drainage. Requires absorbent

cover dressingcover dressing

Change when saturatedChange when saturated


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HealingHealingFill wound cavityFill wound cavity

Hydrofiber (Aquacel)Hydrofiber (Aquacel)

For moist and draining woundsFor moist and draining wounds

Easy to apply. Comes in rope and sheetsEasy to apply. Comes in rope and sheets

Change based on amount of drainage. DailyChange based on amount of drainage. Dailyto every 3 days.to every 3 days.

Turns to gel. Easy and less painful to removeTurns to gel. Easy and less painful to removeand apply.and apply.


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HealingHealing Negative Pressure TherapyNegative Pressure Therapy

KCI Wound VACKCI Wound VAC (Vacuum Assisted Closure)(Vacuum Assisted Closure)

Wound filled with sterile foam. Covered withWound filled with sterile foam. Covered withocclusive drape and attached to negativeocclusive drape and attached to negativepressure pump.pressure pump.

Removes exudate from woundRemoves exudate from wound

Promotes angiogenesis and wound contractionPromotes angiogenesis and wound contraction

Changed 3 times per weekChanged 3 times per week

Reduces exposure to contamination and painReduces exposure to contamination and pain

Expensive.Expensive.

Can be used at home with insurance approval.Can be used at home with insurance approval.

Not covered at home by MedicaidNot covered at home by Medicaid


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HealingHealing Promote a clean wound base freePromote a clean wound base free

from infectionfrom infection Irrigate wound with each dressing change withIrrigate wound with each dressing change with

normal saline or wound cleaner to reducenormal saline or wound cleaner to reducebioburdenbioburden

Antimicrobial dressingsAntimicrobial dressingsAquacel AGAquacel AG

Mesalt (Hypertonic saline)Mesalt (Hypertonic saline)

Wound VAC Silver DressingWound VAC Silver Dressing

Appropriate antibiotic therapyAppropriate antibiotic therapy


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Anti infective AgentsAnti infective Agents

Antibacterial fluids can be added toAntibacterial fluids can be added towet gauze dressings:wet gauze dressings:

Sulfamylon (mafenide)Sulfamylon (mafenide)

Dakins Solution (for short period forDakins Solution (for short period forinfected, odorous wounds)infected, odorous wounds)

Same concerns as previously noted forSame concerns as previously noted forwet to moist dressingswet to moist dressings


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HealingHealing Remove nonviable tissue from theRemove nonviable tissue from the

wound to promote new growthwound to promote new growth

and reduce medium for infectionand reduce medium for infection DebridementDebridement

Surgical:Sharps: immediateSurgical:Sharps: immediate Excisional Debridement removal of tissue and notExcisional Debridement removal of tissue and not

just loose tissue fragments.just loose tissue fragments. Enzymatic: Collagenase/Santyl oint.Enzymatic: Collagenase/Santyl oint.

Apply once or twice a day.Apply once or twice a day.

Cover with dry dressingCover with dry dressing

Necrotic Tissue needs to be scored with scalpelNecrotic Tissue needs to be scored with scalpel

Can be slow processCan be slow process


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HealingHealing Investigate and resolve underlying causesInvestigate and resolve underlying causes

Pressure UlcersPressure Ulcers Pressure reliefPressure relief

Reduce risk of shearReduce risk of shear

Incontinence careIncontinence care

Venous InsufficiencyVenous Insufficiency Compression if arterial involvement ruled outCompression if arterial involvement ruled out

Arterial IschemiaArterial Ischemia RevascularizationRevascularization

Neuopathic/Diabetic UlcersNeuopathic/Diabetic Ulcers Glucose ControlGlucose Control

Off loading footwearOff loading footwear


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HealingHealing CollaborationCollaboration

Physician: Plastics, Vascular, Dermatology,Physician: Plastics, Vascular, Dermatology,

Infectious DiseaseInfectious Disease Nursing, WOCNNursing, WOCN

DietitianDietitian

Diabetic EducatorDiabetic Educator

Physical TherapyPhysical Therapy Social ServiceSocial Service

Home CareHome Care


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Thank YouThank You

pressure ulcers for physicians

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