Professional Documents
Culture Documents
T
he practice of wound care has evolved over the past include co-existing health conditions that may contribute to
decade. Technological advances in local wound the major risk factors for pressure ulceration. Significant
care, pressure reduction and relief surfaces, and uncontrolled diseases that may impact healing include: car-
adjunctive therapies have revolutionized the prevention and diac, renal, gastrointestinal, collagen-vascular, neuromuscu-
management of pressure ulcer care. Six years have passed lar, hematological disorders, and anemia. The history should
since the Agency for Health Policy and Research (AHCPR) review medications with special attention to those drugs that
published its evidence-based guidelines for pressure ulcer may impair healing (ie, systemic corticosteroids, chemother-
management in the United States.1 Since then, other guide- apeutic agents, and nonsteroidal anti-inflammatories).
lines also have been developed in Europe.2,3 Recent acute illnesses or acute exacerbation of chronic
A Canadian consensus panel met and presented at a diseases may cause lethargy, leading to immobility and
national forum at the Canadian Association of Wound Care increasing the risk of pressure ulcers. For example, a stroke
(CAWC) conference in Toronto, Canada in November may significantly alter bed mobility and sensation as well as
1999. lead to nutritional compromise through altered swallowing.
They reviewed the evidence to date and recommended an Ideally, all institutionalized (acute, chronic, or long-term
overall approach to pressure ulcer management. This panel care) patients should be assessed for pressure ulcer risk fac-
focused on: risk assessment, accurate staging and wound tors. End-of-life care may be accompanied by nonhealable
Please address correspondence to: Heather Orsted, RN, 320 17th Avenue SW, Calgary, Alberta T2T 5T1, Canada.
38 OstomyWound Management
In this Stage II pressure ulcer, a persistent area of erythema An eschar with unknown depth does not allow this ulcer to be
shows areas of breakdown, exposing the superficial dermis. accurately staged.
In this Stage IV pressure ulcer, subcutaneous fat is revealed on The pressure ulcer with undetermined depth, shown here, has
the left side and muscle in the deep part of the right-hand a small opening on the surface, revealing extensive
portion of the ulcer. undermining.
Extensive surgical debridement to attached edges uncovered a A calcium alginate rope was used on this pressure ulcer for
deep Stage IV ulcer to joint capsule. hemostasis. Any bleeding vessels require electrocautering or sur-
gical ligation.
40 OstomyWound Management
Computerized pressure mapping can
TABLE 2 be used as a semi-quantitative measure-
HISTORY AND PHYSICAL EXAMINATION ment to evaluate the effectiveness of
pressure reduction or relief surfaces.11,12
Duration of Ulcer Less than 2 weeks Recurrent Ulcer This tool also can help the patient visu-
More than 2 weeks 1st Ulcer Year alize the effects of pressure through
Previous Diagnosis biofeedback. This assessment must be
Previous Treatments used in combination with clinical
Medications
assessment. In the absence of sensation,
Blood pressure
X-ray, Bone scan, CT scan increased pressure will not be translated
CBC, ESR, CRP into pain, and this biofeedback can be
invaluable. Educating staff is para-
Albumin, pre-albumin, Hgb AIc, blood sugar; semi-quantitative swab,
mount to the introduction of high-tech
urinalysis as indicated
Pain assessment Acute noncyclic Acute cyclic Chronic equipment. Despite advancing technol-
ogy, all staff should be taught how to
perform a hand check to determine the
efficacy of the surface/device used and
1. life expectancy of surface how to detect “bottoming out” before it creates a pressure
2. skin moisture control ulcer. To perform a hand check, the caregiver should place
3. skin temperature control an outstretched hand (palm up) under the surface below the
4. redistribution of pressure body part at risk. If the caregiver feels less than an inch of
5. product service requirements support, the patient has bottomed-out.
6. fail safety Clinicians must remember that pressure management is
7. infection only one part of a successful treatment program to prevent
8. flammability and treat pressure ulcers. A therapy that is incorrectly used is
9. patient/product of little benefit and may even be harmful.
10. friction.
Having patients on appropriate surfaces at all times, Recommendation 3
not just when in bed, is important. Support surfaces
8
Assess and Control Pain
can be classified into air fluidized, low air loss, alternat- Krasner reviewed wound pain assessment and manage-
ing air, static flotation, foam, and standard (see Table 3). ment and categorized wound pain into noncyclic acute pain
In 1999, the Cochrane Group systematically reviewed associated with interventions, cyclic acute pain associated
beds, mattresses, and cushions for pressure ulcer preven- with dressing changes or positioning, and chronic wound
tion and treatment. Pressure-reducing foam mattresses pain.13 Analgesia should be provided to control the pain in
and overlays were more effective than standard hospital anticipation of interventions as well as for maintaining con-
mattresses in pressure ulcer prevention in moderate- to trol of chronic pain. Good pain management may improve
high-risk groups. There is good evidence of the effec-
9
mobility and prevent ulcers or facilitate healing. Pain loca-
tiveness of air-fluidized and low-air-loss devices in treat- tion, intensity, duration, type, and acceptable pain levels
ment. In a recent study, Russell and Lichtenstien should be assessed and interventions targeted to the underly-
demonstrated the efficacy of a multicell, pulsating, ing cause. Accurate pain assessment is dependent on the
dynamic mattress system in the prevention of pressure patient’s subjective assessment of the pain. Several tools have
ulcers in patients undergoing cardiovascular surgery.10 been developed to assist the patient in describing pain inten-
Overall, however, it is not possible to determine the sity. A facies scale is useful for young children or those with
most effective surface for ulcer prevention or treatment.10 language difficulties; otherwise, a pain analog score is very
Decision-making algorithms such as the one in the useful where 0 indicates no pain and 10 indicates the worst
AHCPR guidelines have been helpful in the selection of pain the patient has ever experienced. Pain due to irritation
the most appropriate surface. 1
of the normal nerve fiber is usually represented by a dull
42 OstomyWound Management
Patients and their caregivers should be instructed on the importance of nutri-
tion in relation to wound healing, and nutritional support should be offered as
needed.19 Assessment and correction of dehydration is important to optimize heal-
ing. Fluid may be lost through exudating wounds, and in elderly patients, fluid
intake may be poor and replacement inadequate.
Recommendation 5
Control Moisture and Incontinence
Excessive moisture on the skin may be a result of perspiration, wound
drainage, soaking during bathing, or fecal or urinary incontinence. This may
cause maceration of the skin and put the skin at an increased risk for trauma.
Moisture – particularly moisture secondary to incontinence – is acknowledged
as a primary risk factor for the development of pressure ulcers. Fecal inconti-
nence is a greater risk factor than urinary incontinence.20 Nursing staff need to
be aware of the medical problems that may lead to incontinence, the symp-
toms describing the many types of incontinence, and the therapies that may
lead to control.21 Research has shown, that when properly assessed and treated,
urinary incontinence can be corrected in about 30% of nursing home resi-
dents.21
In adults, a single event of incontinence is unlikely to lead to skin breakdown.
Rather a series of events that weaken the skin and make it vulnerable to further
damage is what is likely to result in this breakdown.20 Increased friction and shear,
poor nutrition, disease, and pressure all aggravate compromised skin. Even the
chemical irritation of frequent washings with soaps can cause irritation.22 The
adhesiveness of moist skin to bed linens is estimated to increase the risk of ulcera-
tion fivefold.23 The underlying etiology of the moisture needs to be identified and
removed. Catheters often are used to control incontinence when trying to heal a
pressure ulcer to eliminate urinary contamination entirely. Long-term, indwelling
catheters have been associated with increased incidence of sepsis and death and
should be used with caution.
Barrier creams, ointments, and polymeric film-forming skin protectants can
be used to reduce the impact of moisture from urine and feces on the skin.24
The compatibility of the cream or ointment with the absorbent pads used to
manage incontinence should be determined. Absorbent products are not
equal, and their benefits need to be evaluated according to the needs of the
patient. Odor control, wick-away properties, absorbency, concealability, com-
fort, and cost all must be considered. Condom catheters, pouches, and collec-
tion devices are also available. Trauma related to incorrect application of con-
dom catheters is common, and correct sizing and application is important.
Extensive information on continence is available via the Canadian Continence
Foundation website at: http://www.continence-fdn.ca/.
Excessive sweating can be related to medication, infection, or the environment
and may not be controllable. The patient should be instructed on how sweating
impacts skin integrity and that wearing breathable clothing can make a big impact
and can lower the risk of yeast infection in skin folds. Excessive wound exudate
may be managed with appropriate dressing selection (alginates, foams, composites,
and hydrofibers), or pouching may be considered if the wound is appropriate.
Recommendation 6 stress has on the healing of wounds. The psychological
Maximize Activity and Mobility, Reducing or impact of a pressure ulcer can cause social isolation and cre-
Eliminating Friction and Shear ate an immeasurable level of burden and frustration for the
Shear is a mechanical force that moves the bony struc- patient, healthcare professionals, family, and caregivers.
tures in a direction opposite the overlying skin (tearing Patients with debilitating wounds often have body image
force). The effects of pressure are compounded by the addi- disturbances and low self-esteem.19 Therefore, completing a
tion of shear. This may reduce the amount of pressure need- psychosocial assessment to identify any psychological stres-
ed to produce vascular occlusion by one-half. Shear also may sors is beneficial. The interdisciplinary team is required to
account for clinical observations of large areas of tunneling assess the need for and focus intervention on the following
or deep sinus tracts beneath sacral ulcers. Maintaining the three areas:
head of the bed below 30 degrees and appropriate position- 1. The patient’s network: social interaction in the
ing in wheelchairs will decrease the risk of shearing.23 family, circle of acquaintances, culture and ethnici-
Friction is the force of two surfaces moving across one ty, and social support
another, creating local heat and often resulting in an abra- 2. The patient’s living space/environment: living con-
sion. Postoperative patients may be at increased risk from ditions, everyday capabilities, and occupational
complications, including immobilization as well as low resources (ie, availability and skill of caregivers,
blood pressure.25 Friction commonly occurs in patients who finances, and equipment)
are unable to lift themselves sufficiently for repositioning. 3. The patient’s personal space: patient compliance,
Turning sheets and trapeze bars may assist with mobility cognitive and emotional state, depression, quality
and decrease risk of friction.23 of life, mental status, learning ability, multiple
The interdisciplinary team and patient should determine medications, or overmedication, alcohol and/or
the relevant etiology of the ulcer and develop a correspond- drug abuse, goals, values and lifestyle, sexuality,
ing patient-centered treatment program. stressors, and pain as a symptom.3
Educational programs can be offered to assist with a
Recommendation 7 proactive approach to the prevention of pressure ulcers.19
Assess and Assist with Psychosocial Needs When patients are involved in their own care, they can
Pressure ulcers impact patients not only physically, but become committed to seeing a positive outcome because
also psychologically, stripping away dignity and indepen- they feel responsible for the success of the treatment regi-
dence.26 The complex interplay of psychosocial factors that men. This can help patients gain a sense of self-control.19
occurs as a result of pressure ulcer development can increase Ultimately, the aims of therapy should be to relieve suf-
the risk of pressure ulcer formation. Kiecolt et al27 demon- fering and to achieve a healed wound as efficiently and effi-
strated in their study the detrimental effect psychological caciously as possible.
TABLE 4
NPUAP STAGING SYSTEM
Stage Description
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 also may be indicators.
II Partial-thickness skin loss involving epidermis or dermis or both.The ulcer is superficial and presents
clinically as an abrasion, blister, or shallow crater.
III Full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to
but not through underlying fascia.The ulcer presents clinically as a deep crater with or without
undermining of adjacent tissue.
IV Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or sup-
porting structures (such as tendon and joint capsule)
44 OstomyWound Management
TABLE 5
PUSH TOOL 3.0
Length 0 1 2 3 4 5
0 cm2 < 0.3 cm2 0.3 – 0.6 cm2 0.7–1.0 cm2 1.1-2.0cm2 2.1-3.0cm2
x Width 6 7 8 9 10 Subscore
3.1– 4.0 cm2 4.1–8.0 cm2 8.1-12.0 cm2 12.1-24.0 cm2 > 24.0cm2
Exudate 0 1 2 3 Subscore
amount none light moderate heavy
Tissue 0 1 2 3 4 Subscore
type closed epithelial granulation slough necrotic
tissue tissue tissue
Total score
46 OstomyWound Management
tional therapy. More than 10 clinical reports exist in the ulcers. Research evidence suggests that both of these relative-
recent literature that consistently demonstrate the ability of ly new wound treatments can stimulate cell activity via
electrical current to accelerate wound closure rate of chronic mechanical stretching of key cellular components of the
pressure ulcers. Eight of these clinical trials are properly wound healing process.
designed, randomized controlled studies.42 This evidence Laser treatment for chronic pressure ulcers should be
supports the AHCPR recommendation regarding the use of considered experimental and used only when other
electrical stimulation for the treatment of chronic pressure adjunctive modalities are not available. Although numer-
ulcers that failed to heal by conventional treatment.1 These ous reports suggest that lasers can stimulate the prolifera-
guidelines were revisited in a 1998 review of the literature.40 tive phase of wound healing, this experimental research
Based on results from new clinical reports, the strength of has been plagued by inconsistent results. Skepticism
evidence of the use of electrical stimulation on chronic regarding the effects of laser treatment on wound healing
wounds was upgraded to the highest rating. has been fuelled by the lack of randomized controlled
Chronic pressure ulcers treated with therapeutic ultra- clinical trials demonstrating the benefits of laser for the
sound, ultraviolet light, or pulsed electromagnetic fields may treatment of chronic wounds. Because the clinical effec-
have accelerated rates of closure. At least four research stud- tiveness of laser treatment has not been well documented,
ies, including two well-designed, randomized controlled tri- the use of laser in the United States can only occur under
als, have assessed the effectiveness of ultrasound in the treat- an investigational FDA exemption (Center for Devices
ment of chronic pressure ulcers.42 These clinical studies, per- and Radiological Health, FDA Fact Sheet: Laser
formed on chronic pressure ulcers, together with other Biostimulation. Division of Consumer Affairs, 1984).
reports of the benefits of therapeutic ultrasound on chronic Three recent clinical reports document accelerated closure
venous ulcers, suggest that therapeutic ultrasound may pro- of recalcitrant pressure ulcers following the application of a
mote closure of chronic wounds.43 Some conflicting clinical noncontact moist heat bandage to the local wound environ-
reports failed to demonstrate a significant effect of ultra- ment.55-57 The benefits on wound healing may be due to
sound on wound closure. heat-induced local tissue perfusion and oxygen produced in
Inhibitory effects of ultra violet light in the C range the wound bed.58 None of these reports involve comparisons
(UVC) on bacterial growth are well established and are to an appropriate control group.
believed to occur through direct effects on the cell nucleus Hydrotherapy may be used to cleanse and debride
and DNA synthesis of the bacteria.44,45 Recent reports of the necrotic pressure ulcers but should be discontinued when
inhibitory action of UVC on antibiotic resistant strains of the ulcer is considered clean. Clinical reports suggest that
bacteria46 warrant consideration of the use of this modality hydrotherapy can reduce bacterial contamination of chronic
for the treatment of chronic infected wounds. At least four ulcers.62,63 However, conflicting research suggests that
clinical reports, including two randomized clinical trials, wounds treated with hydrotherapy are at risk for water-
document that ultraviolet light treatments accelerate closure borne infection64 and other complications.65 Hydrotherapy
of chronic infected pressure ulcers.47,48 UVC has a mutagenic administered via jet lavage has been suggested for use on
effect on human cells and should be used with caution espe- necrotic wounds with undermining.66 The benefits of
cially in younger individuals. hydrotherapy in promoting new tissue formation of clean,
Application of electromagnetic fields (EMFs) has been nonhealing ulcers have not been documented.
shown in three clinical reports and one randomized con- To date, electrical stimulation and ultrasound are the only
trolled clinical trial to significantly accelerate the closure of adjunctive therapies that have been recommended for use
pressure ulcers.49-51 In addition, significant changes in local on chronic ulcers. Other therapeutic modalities have limited
blood flow, skin temperature, subcutaneous tissue oxygena- clinical research evidence to support their use in clinical
tion, and local edema have been demonstrated following practice.
administration of pulsed magnetic fields.52-58
Limited clinical research evidence, including case Recommendation 10
reports,59 retrospective analysis,60 and noncontrolled clinical Consider Surgical Intervention for Deep,
studies,61 document the benefits of constant tension approxi- Nonhealing Ulcers (Stages III and IV)
mation and vacuum-assisted closure on chronic pressure In the infected or high-risk patient, operative intervention
is still indicated despite improvement in current outpatient care, the proliferation of wound care products, new tech-
regimens. The surgical debridement of deep ulcers and nology, legal responsibilities, and best practice issues can
infected vital structures still requires the specialized facilities overwhelm the bedside caregiver of a patient with a pres-
of an operating room; albeit, increasingly on an outpatient sure ulcer. Wound care teams provide support in the
basis.2 However, optimal wound debridement often requires areas of education, research, and patient care (see Table
combined use of surgery and other modalities.67,68 One study 6)77 and may consist of RNs, LPNs, PTs, OTs, physi-
has shown that pulsatile lavage is more effective than cians, dietitians, social workers, and others as required by
whirlpool therapy.69 Collagenase has now been shown to be the needs of the patient.
cost-effective and significantly faster than hydrogel in the Granick and Ladin77 report that after the integration
debridement of heel ulcers and dermal leg ulcers.70 The fact of a multidisciplinary team, the overall prevalence of
that collagenase is a temperature-sensitive enzyme supports pressure ulcers declined from 22.6% in 1993 to 8% in
the use of warming in pressure ulcer patients. Use of fascio- 1996 in one hospital. A 15% decrease in 1 year was
cutaneous flaps were shown to be of greater benefit in pro- reported in their investigation in another hospital. The
viding stable closure in one series of patients71-73 and in some prevalence of ulcers, as well as the recurrence rate in
nonhealing pressure ulcer patients. Myocutaneous flaps and high-grade ulcers treated surgically, was reduced as a
island fasciocutaneous flaps are still popular as surgical alter- result of multidisciplinary teams.75-77 Bateman78 states
natives which, if carefully planned, can provide a stable the strongest component that differentiates one wound
cover.74,75 Prevention of ulcers by warming and methods of care program from another is the wound care team.
recording pressure in intraoperative patients has been stud- She brings forth four key questions to ask about the
ied by Scott et al.11,74 team:
Early rehabilitation and inclusion of a rehabilitation team 1. How qualified is the staff?
in postoperative management has been found effective in 2. What educational tools do they utilize?
reducing hospital costs.75 3. How do they measure patient outcomes?
Certainly, with the use of multidisciplinary teams, the 4. What does their patient population have to say
outcomes of surgical pressure ulcer management, the out- about their program?
comes of surgical and nonsurgical pressure ulcer manage- Best practice carried out by a dedicated wound team
ment, the number of ulcers has been on the decline for in- can be an effective means of achieving improved out-
hospital managed patients. Regardless of how wound man- comes in pressure ulcer management. A panel discus-
agement is carried out, the recognized endpoint accepted by sion from the 12th Annual Clinical Symposium cau-
the FDA is total wound closure. All preventative measures tions that developing and maintaining a team is an art.
must be reinstituted in postsurgical patients on discharge or The team members must understand and apply the lit-
the recurrence rate is unacceptably high. erature on team building to the unique characteristics
of ones facility.79 Panel member David Thomas states,
Recommendation 11 “Teams must be built in terms of human relationships.
Develop an Interdisciplinary Team Specific to the In practical ways, you have to become involved with
Needs of the Patient each other and break down barriers that may exist
Increased complexity of patients, fragmentation of between disciplines.”
48 OstomyWound Management
Recommendation 12 Pressure Ulcers. Rockville, Md: US Department of
Educate Patients, Caregivers, and Healthcare Health and Human Services. Public Health Service.
Professionals on the Prevention and Treatment of Agency for Health Care Policy and Research; 1992.
AHCPR Publication 95-0652.
Pressure Ulcers
2. Benbow M, Burg G, Camalio-Martinez F, et al. In:
The importance of preventing recurrence bears repeating.
Health Force Initiative 159. Berlin, Germany:
Education of the patient is tantamount to preventing recur-
Blackwell Science; 1999.
rence and requires education of the primary caregiver, the 3. Cherry CW. New European initiatives in the stan-
patient’s family, and other involved healthcare professionals. dardization and treatment of pressure ulcers. Wound
Phillips80 recommends that educational programs for health- Repair and Regeneration. 1998;6(5):A461.
care providers, patients, families, and caregivers cover the 4. Bergstrom N, Braden BJ, Laguzza A, Holman B. The
following topics, with content modified according to the Braden Scale for predicting pressure ulcer risk. Nurs
audience: Res. 1987; 36(4):205-210.
• pathophysiology and risk factors for pressure 5. Norton D, McLaren R, Exton-Smith AN. An inves-
damage tigation of geriatric nursing problems in hospitals.
• risk assessment tools and their application London, England: National Corporation For The
• skin assessment Care Of Old People, 1962.
6. Goodridge DM, Sloan JA, LeDoyan YM, MacKenzie
• selection and instruction in the use of pressure
J, Knight WE, Gayari M. Risk assessment scores and
redistribution and other devices
the incidence of pressure ulcers among the elderly in
• developing and implementing individualized pro-
four Canadian health-care facilities. Canadian
grams of care Journal of Nursing Research. 1998;30:23–44.
• principles of positioning to decrease risk of pressure 7. Krouskop TA, van Rijswijk L. Standardizing perfor-
damage mance based criteria for support surfaces.
• documenting processes and patient outcome data Ostomy/Wound Management. 1995;41(1):34–35.
• clarifying responsibilities for all concerned with the 8. Grey JE, Rees-Mathews S, Hardin KG. Pressure
problem relief: resting on our laurels. Wound Repair and
• health promotion Regeneration. 1998;6:A467.
• development and implementation of guidelines. 9. Cullum N, Deeks J, Sheldon TA, Song F, Fletcher
AW. Beds, mattresses and cushions for pressure ulcer
Phillips advises that the content should be updated regu- prevention and treatment (Cochrane Review). In:
The Cochrane Library, Issue 3. Oxford: Update
larly on the basis of best evidence.
Software: 1999.
10. Russell JA, Lichtenstien SL. Randomized controlled
Conclusion trial to determine the safety and efficacy of a multi-
Six years have passed since the publication of the cell pulsating dynamic mattress system in the preven-
AHCPR guidelines. Because it is an evolutionary document, tion of pressure ulcers undergoing cardiovascular
it needs to be updated periodically so that the guidelines can surgery. Ostomy/Wound Management.
be revisited. This task is a large one, requiring the input of 2000;46(2):46–55.
consensus groups. The Canadian Association of Wound 11. Sasche. Evaluation of pressure relief mattresses. Plast
Care advisory panel on pressure ulcer management intended Reconstr Surg. 1998;102:2381.
to create a more international approach while maintaining 12. Scott EM, Garbett EA, Stoddard E, Leaper DJ. The
the quality of content and has proposed the new recommen- prevention of pressure ulcers in surgical patients:
dations included in this paper with the hope that all practi- evaluation of intra-operative mattresses through the
tioners will be able to use the recommendations to serve as measurement of interface pressures. Wound Repair
and Regeneration. 1998;6(5):A479.
best practice enablers. - OWM
13. Krasner D. The chronic wound pain experience: a
conceptual model. Ostomy/Wound Management.
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50 OstomyWound Management
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52 OstomyWound Management