Wound and Pressure Ulcer Management

What is a Pressure Ulcer?

Wound and Pressure Ulcer Management

Previously called decubitus or bed sore, a pressure ulcer is the result of damage caused by pressure over time causing an ischemia of underlying structures. Bony prominences are the most common sites and causes.

There are many risk factors that contribute to the development of pressure ulcers. CMS (2004) recommends patients in LTC be assessed for risk on admission, weekly for the first four weeks then reassessed quarterly.

There are many contributing factors.

Intrinsic contributing factors include:

Malnutrition
Dehydration
Impaired mobility
Chronic conditions
Impaired sensation

Decreased LOC
Infection
Advance age
Steroid use
Pressure ulcer present

External contributing factors include:

Pressure
Friction
Moisture
Incontinence
Shear

How Do You Prevent a Pressure Ulcer? (WOCN 2003; AHCPR 1992)

Proper skin care is crucial and involves inspecting skin daily and an individualized bathing schedule, using warm (not hot) water and mild soap. Avoid massage over bony prominences and use lubricants if skin is dry.

Managing pressure is also necessary and the following is recommended.

Provide appropriate support surface
Reposition every two hours in bed
Off-load heels - use pillows or positioning boot
Reposition every hour when in chair
Use pillow between legs for side lying
Do not position directly on trochanter
Do not use doughnut-type devices

Friction and shear need to be reduced. Friction is the mechanical force exerted when skin is dragged against a coarse surface while shear is the mechanical force caused by the interplay of gravity and friction. It exerts a force parallel to the skin resulting in angulation and stretching of blood vessels (shown below on right) within the sub-dermal tissues, causing thrombosis and cellular death. This manifests as necrosis and undermining of the deepest layers (Pieper 2007).

To reduce friction and shear, the following is recommended:

Use draw sheets for repositioning
Encourage use of trapeze if possible
Keep head of bed elevated ? 30? if tolerated
Elevate foot of bed slightly, if condition permits
Use pillow or wedge to support hip for 30? side-lying, lateral position
Utilize lifts and transfer devices
Rehabilitation or Restorative care if indicated

Manage Incontinence

Timely cleansing
Apply barrier ointment to intact skin
If skin is red or denuded use a paste
Use appropriate incontinence disposables
Apply fecal incontinence pouch if needed

What is Not a Pressure Ulcer?

Skin tears, denuded or excoriated skin, arterial ulcers, venous stasis ulcers and diabetic/neurotrophic ulcers are NOT pressure ulcers.

Skin Tear Prevention (Ayello 2003)

Wash with gentle cleansing products
Use emollients on skin
Ensure adequate hydration/nutrition
Transfer techniques to avoid friction/shear
Support dangling extremities
Avoid use of adhesive products on skin

Venous Ulcer Prevention (Vowden & Vowden 2006)

Use of compression stockings (contraindicated if ABI < 0.5)
Elevation of effected leg above level of the heart at rest
Avoid use of products likely to be sensitizers (lanolin, fragrances)
Avoid trauma to legs
Calf muscle strengthening
Regular follow up to monitor ABI

Prevention of Limb loss in Lower extremity arterial disease (Hopf et al. 2006)

Consistent use of protective footwear
Avoid friction, shear or trauma to feet/legs
Apply emollients to keep skin pliable
Avoid cold, caffeine, nicotine and constrictive garments
Planned graduated walking program
No use of thermal devices
Routine professional foot care

Prevention of neuropathic ulcers (Steed et al. 2006)

Control diabetes
Daily care and inspection of feet
Wear well-fitting protective footwear
Avoid application of external heat
Avoid use of OTC meds for corns/callous
Avoid cold, caffeine, nicotine and constrictive garments
Routine professional foot care

Assessment (Nix 2007)

Holistic Assessment

Holistic assessment of a patient with a wound includes systemic factors, psychosocial factors, and local factors.

Systemic factors assess etiology, duration, and decreased oxygenation or perfusion of the wound as well as comorbid conditions, medications, and host infection of the patient.

Psychosocial factors to address in a holistic assessment include the patient’s knowledge deficits, cultural beliefs and financial constraints including a lack of or insufficient health insurance. Additionally, it is necessary to assess whether the patient has impaired access to appropriate resources and any social support – family, significant others or community resources.

Local factors to assess include desiccation, excess exudates, low wound temperature, recurrent trauma (also friction & pressure), infection, and necrosis and foreign bodies.

Wound Assessment

An assessment of the wound should be done weekly and be used to drive treatment decisions. Wound assessment includes: location, class/stage, size, base tissues, exudates, odor, edge/perimeter, pain and an evaluation for infection.

Location
Documentation of location indicating which extremity, nearest bony prominence or anatomical landmark is necessary for appropriate monitoring of wounds. (Hess 2005)

Class/Stage
Pressure ulcers are classified by stages as defined by the National Pressure Ulcer Advisory Panel (NPUAP). Originally there were four stages (I-IV) but in February 2007 these stages were revised and two more categories were added, deep tissue injury and unstageable.

Pressure Ulcer Staging
Stage I - Intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister.

Stage III - Full thickness skin loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining/tunneling.

Stage IV - Full thickness skin loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

(Suspected Deep) Tissue Injury - Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. (NPUAP 2/07)

Class
There are a number of classification and grading systems used in wound care but the simplest method uses the terms partial thickness or full thickness
• Partial thickness wound (PTW): damage to epidermis and/or dermis only
• Full thickness wound (FTW): damage to subcutaneous layer or deeper

Size
Measurement

Length – from top edge to the bottom edge (head to toe) at longest point
Width – from edge to edge perpendicular to the length at widest point
Depth – straight in, perpendicular to the base, at deepest point

Undermining/Tunneling

Using the “clock concept” (12 o’clock is in the direction of the patient’s head and 6 o’clock is toward the feet)
Where does it start and where does it end (clockwise direction)
Tunnel depth is at it’s deepest point
Location of deepest point

Base Tissues
Assessing the appearance of tissue in the wound bed is critical for determining appropriate treatment strategies and to evaluate progress toward healing. (Keast et al. 2004)

Necrosis/Eschar - Black, brown or tan devitalized tissue that adheres to the wound bed or edges and may be firmer or softer than the surrounding skin.
Slough - Soft, moist avascular tissue that adheres to the wound bed in strings or thick clumps; may be white, yellow, tan or green.
Granulation - Pink/red moist tissue comprised of new blood vessels, collagen fibers and fibroblasts. Typically the surface is shiny and moist with a granular appearance.
Epithelium - New pink and shin tissue/skin that grows in from the edges or as islands on the wound surface.

Exudates
Amount

None – base and dressing dry
Slight – small amount in center of dressing
Moderate – contained within the dressing
Copious – extends beyond dressing onto clothing or bed linen

Type

Serous – thin, watery, clear or straw colored
Serosanguineous – thin, pale red to pink
Purulent – thick, opaque, tan, yellow to green and may have an offensive odor
Consider treatment modality and frequency of dressing changes

Odor
Assess after cleansing (Garcia & Thomas 2006). Extreme malodor, especially if accompanied by purulent exudates is suggestive of infection. Most wounds do have an odor. The type of dressing can affect odor as well as hygiene and the presence of nonviable tissue (Keast et al. 2004).

Edge/Perimeter

Describe wound edges (approximated, rolled, calloused)
Describe periwound skin (indurated, erythematous, macerated, healthy)
Describe presence of excoriation, denudement, erosion, papules, pustules or other lesions

Induration - Abnormal hardening of the tissue caused by consolidation of edema,
this may be a sign of underlying infection.
Erythema - Redness of surrounding tissue may be normal in the inflammatory stage of healing. However, if accompanied by an increase in temperature of tissue, exudates or pain may also be a sign of infection.
Maceration - Caused by excessive moisture, Tissue loses its pigmentation (appears lucid or turns white) and becomes soft and friable.

Pain
A critical aspect of local wound assessment both from the perspective of the patient and as a clinical indicator of infection. (Reddy, Keast, Fowler & Sibbald 2003) Include location, type/cause, rating (use validated scale), patient description and nonverbal signs.

Evaluation of infection
Infection – Signs and Symptoms:

Redness, warmth and induration of adjacent tissues
Pain or tenderness
Dysmorphic and/or friable granulation
Unusual odor
Purulent exudates
Systemic signs (fever, chills, sweats)

When to Culture: (Dow 2003)

When signs of infection are present or when a clean wound fails to heal
Always cleanse wound first
Semi-quantitative swab collection is acceptable
Quantitative biopsy is “gold standard” but expensive and invasive

Additional Assessment for Lower Extremity Wounds (WOCN 2002)

Physical Exam

Edema –extent and persistence of pitting (1+ - 4+)
Color changes - dependent rubor (purple-red discoloration) or elevation pallor (paling of the skin when leg raised to a 60° angle for 15 -60 seconds)
Distal pulses –amplitude on palpation (0 – 4+)
Neuropathy – skin changes (dryness, cracking), structural abnormalities, and loss of protective sensation (10gm monofilament exam – testing 10 points)

Diagnostic Tests

Ankle-Brachial index – comparison of perfusion pressures
Pulse volume recording - perfusion volume
Doppler waveforms – single vessel flow
Duplex imaging – ultrasound imaging for venous disease (also test for DVT)
Transcutaneous oxygen pressure (TcPO2)

Wound Healing

Phases of Wound Healing

There are three phases of wound healing - inflammation, proliferation, maturation

Inflammatory Phase

0 – 3 days
Hemostasis (bleeding stops)
Inflammation (redness, swelling, warmth and pain maybe present)
Phagocytosis (WBC’s engulf bacteria and foreign debris)
Growth factor stimulation stimulation

Proliferation Phase

3 – 21 days
Angiogenesis (new blood vessels develop)
Collagen synthesis (protein fibers)
Granulation formation
Epithelialization
Contraction

Maturation Phase

21 days – 2 years
Reorganization of collagen
Tensile strength improves (up to 80% of original)

The healing process varies depending on the stage of the pressure ulcer. Stage I & II pressure ulcers and partial thickness wounds heal by tissue regeneration. Stage III & IV pressure ulcers and full thickness wounds heal by scar formation and contraction. Data indicate a 20% reduction in wound size over two weeks is a reliable predictive indicator of healing. (Flanagan 2003)

Optimization of Wound Environment

Manage comorbid conditions
Adequate nutrition & hydration
Remove nonviable tissue
Maintain moisture balance
Protect the wound and periwound skin

Eliminate or minimize pain
Cleanse
Prevent and manage infection
Control odor

Manage comorbid condition

Optimize cardiovascular and pulmonary functioning
Support tissue oxygenation
Maintain blood glucose control

Adequate nutrition & hydration (Harris & Frasier 2004)

Encourage protein, calorie-dense foods and fluids, unless contraindicated
Monitor intake, weight and skin turgor
Assess and address impairments in dentition and swallowing
Assist patients with meals if needed
Dietary consult

Eliminate or Minimize Pain

Address the cause (remove the source if external, treat the infection or medicate based on physiological stimulus)
Pharmacological strategies –long acting drugs preferable, use breakthrough doses and prevent adverse effects
Incorporate psycho-social, spiritual and culturally sensitive support
Appropriate dressing selection, gentle removal and “Time out” during treatment administration

Cleanse

Normal saline is the recommended solution
Cavity wounds or tunnels may be irrigated
Apply 4-15 (psi) pressure/force to remove debris without harming healthy tissue

Protect Wound and Periwound Skin

Use barrier products to protect from adhesives and moisture
Change dressings at appropriate intervals to avoid pooling of exudates

Prevent and Manage Infection
Critical colonization can result in failure to heal, poor quality tissue, increased friability and increased drainage (Frank, Bayoumi & Westendorp 2005). Determining whether the wound has a bacterial imbalance (critical colonization and infection) is of primary importance to healing (Sibbald, Woo & Ayello 2006).

Superficial increased bacterial burden – topical agent with low toxicity, not likely to cause allergy and not associated with bacterial resistance
Surrounding skin compartment infection – topical agent, swab culture and appropriate oral antibiotic agent (Sibbald 2003)
Deep wound infection or osteomyelitis – parenteral antibiotics. Also consider tissue culture and additional lab tests (Frank et al. 2005)

Removal of Nonviable Tissue (Debridement)
Removes growth medium, controls/ prevents infection, defines extent of the wound and stimulates the healing process.

Contraindications

Dry stable heel eschar
Ischemic wounds with dry gangrene
Coagulation disorders

Types of Debridement

Autolytic debridement
- Lysis of necrotic tissue by the body’s white blood cells and enzymes.
- Leaves healthy tissue intact
- Naturally occurring physiological process that occurs in a moist environment

Chemical Debridement - Accomplished by topical application of enzymes:
- Collagense (Santyl®)
- Papain with urea (Accuzyme®, Ethezyme®, Gladase®)
- Denaturing agents are also used: Sodium hypochlorite (Chlorpactin®, Dakin’s) Note: This is a nonselective method

Mechanical Debridement
- Wet to dry dressing (not recommended as it is nonselective, causes repeated trauma to the wound bed and is frequently painful)
- Whirlpool (risk of cross contamination and contraindicated for some wounds such as venous stasis)
- Pulse lavage (requires skilled clinician, rigorous infection control precautions and may be cost prohibitive
Sharp Debridement
- Conservative, sequential removal of avascular tissue, using sterile scalpel and mouse-tooth forceps
- Check for bleeding or clotting problems
- Pre-medicate if wound is painful
- Avoid local anesthetic
Surgical Debridement

Maintain Moisture Balance (Rolstad & Ovington 2007)

Dressings with a high moisture vapor transmission rate will allow moisture to escape and evaporate in minimally exudative wounds
Moderate to heavily draining wounds require absorptive dressings

Control Odor

Appropriate frequency of dressing changes
Cleanse with each dressing change
Debridement and antimicrobials as indicated
Charcoal dressings

Treatment

Objectives and Plan

The provider’s role is to assist in the development of a sustainable plan designed to help achieve mutually agreed upon goals. (Nix & Pierce 2007) Treatment goals should be identified and can be curative or palliative. Palliative care objectives focus on symptom management and quality of life.

The objectives vary depending on the staging of the wound:

Recently closed wound, Stage I pressure ulcer, denuded or excoriated skin - Encourage adequate perfusion and protect from further tissue damage.
Stage II or PTW - Encourage regeneration of tissue and protect wound surface.
Stage III/IV - Promote granulation and contraction (epithelialization)

Palliative Wound Care (Bradley 2004)

Symptom management: elimination or reduction of pain, control of odor and exudates, treatment/prevention of infection
Quality of life objectives: restoration of some sense of control, maintenance of function and independence, control of caregiver burden, reduction of distress for patient and family.

Factors for Dressing Selection

Etiology
Exudates
Wound history
Odor
Comorbid conditions
Perimeter
Size
Patient/caregiver needs
Base
Access

Etiology - The cause of the wound directly affects dressing choices. For example:

Arterial ulcers generally require moisture
Neuropathic wounds often have tunnels which require packing strips
Pressure ulcers often have undermining which requires packing to fill dead space
Venous insufficiency requires compression and exudate management

Wound History

Duration and course of wound healing
Previous dressings/treatment strategies
Health care providers consulted for wound
Success/challenges of previous treatment

Comorbid conditions

Diabetes – impairs wound healing, compromises perfusion and there is an increased risk of infection.
Mixed (arterial and venous disease) or CHF - compression may be contraindicated
Obesity – increased risk of venous hypertension, infection and dehiscence (Wilson & Clark 2003)
Immunosupression – increases risk of infection and impairs healing

Size

Size and extent of tissue loss determines both the dressing size and material
Wound packing needed for larger wounds
Exposed tendons/ligaments require moisture and protection

Base

Clean healthy granulation – keep moist
Slough – debridement: If slight amount, keep moist to encourage autolysis, If there is a moderate amount, use a chemical or mechanical agent. For large amounts, perform serial sharp debridement and may also use adjunct treatment with chemical or mechanical agent.
Epithelium- moist protective dressing

Exudates

The volume and type of exudates are significant determinants in selection of primary and secondary dressings
Adequate containment of exudate is critical to manage increased bioburden , protect the periwound skin, control odor and avoid overuse of wound care products (Rolstadt & Ovington 2007)

Odor

Commonly associated with an infected wound
Fungating lesions or wounds with high colonization due to necrotic debris may be malodorous
Odor may cause considerable patient/ caregiver stress and embarrassment

Perimeter - Condition of the periwound skin influences the type of products used and may indicate the need for additional products.

Barriers are indicated for fragile or compromised skin
Maceration indicates need for exudate management
Topical treatment may be required for fungal infections

Patient/caregiver needs

Who is providing the care?
Do they have cognitive, dexterity or visual impairments to consider?
In what setting will the dressings be done?
Are education and/or training needed?
Are health care resources available?
Is the treatment plan congruent with the culture/beliefs of the patient/caregiver?

Access

Does the patient have access to supplies and services?
Are there financial constraints or limitations with insurance coverage?
Is transportation a factor in accessing care or supplies?

Product Categories (Sibbald 2003) (Okan et al. 2007) (Nix 2007)
There are a great deal of products focused on wound management. Below is a breakdown of products by their role in wound and ulcer care.

Antimicrobials (topical)

Bacitracin®, - Broad spectrum, low cost, apply daily.
Bactroban®) - Excellent penetration, effective for MRS. Apply three times daily.
Cadexomer Iodine (Iodosorb®) – Contains microspheres that absorb bacteria while slowly releasing iodine and is less toxic to granulation. Broad spectrum, including virus and fungus. Effective for up to 72 hours.
Nanocrystalline silver (Acticoat 7®) – Releases bactericidal concentrations up to 7 days. Use sterile water, not saline. May stain skin. May be cost prohitive.
Polysporin® powder – For Gram-negative and Gram positive organisms and Pseudomonas. May use with Santyl®. Apply daily.
Silver sulfadiazine (Silvadene®) cream – Broad spectrum. Cost effective, but requires prescription. Avoid in sulfa allergy. Apply daily.
Silver impregnated hydrofiber (Aquacel Ag®) – Highly absorbent. Silver stays in dressing, very little is deposited into wound base. Change when saturated
Silver gel (SilvaSorb®) – Broad-spectrum and low toxicity. Delivers time-released silver for 3 days.
Sodium hypochlorite (Chlorpactin®) – Most appropriate for malodorous wounds with large amounts of slough. Twice daily for short term treatment only (less than 10 days).

Alginates

Derived from seaweed
Highly absorbent and biodegradable
Hemostatic properties
Conforms to wound shape
Maintains moist environment
Virtually painless removal
Examples - Calginate®, Algisite®

Barriers - Primary function - protection

Clear liquid – Skin Prep®, No Sting®
Petrolatum based – Vaseline®, A&D®
Pastes – Criticaid®, Sensicare®
Powders – Stomahesive®, Karaya®
Solids - Stomahesive® wafer, Eakin® seal
Charcoal
Activated charcoal dressings adsorb volatile odors and bacteria
Also available with silver which enhances bactericidal properties
Examples - Clinisorb®, Actisorb®

Collagen – to stimulate wound repair and epithelial activity

Mild absorptive capacity
Usually derived from bovine source (check for patient sensitivity)
Examples - Fibracol®, Profore®

Composite products
Most have three layers: a semi-adherent or non-adherent layer to protect the wound bed, an absorbent layer and a moisture vapor permeable layer with an adhesive border.
Examples – Covaderm Plus®, Alldress®, CovRsite®

Compression wraps

Applied by trained professionals to reduce edema by increasing venous return
Available as two, three or four layers
Degree of tension used in application is critical to effectiveness
Contraindicated in severe LEAD and CHF
Examples – Coban®, Coflex®, Profore®

Foams

Made from hydrophilic polyurethane
Highly absorbent
Decreases maceration of periwound tissue
May be used as primary dressing for treatment of hypergranulation
Examples- Biatain®, Allevyn®, Polyderm®

Gauze

Material may include cotton, rayon and/or polyester
Available in rolls, strips or squares
Adheres to wound tissue
May lint or shred if cut

Hydrocolloids

Contain carboxymethylcellulose (CMC) combined with pectin
Mildly absorbent
Maintains moist wound surface
May have an acrid odor when removed
Not recommended for ischemic wounds (due to occlusive properties)
Examples – Duoderm®, Tegasorb®

Hydrofiber

Composed of highly absorbent CMC
Absorbs twice as much as alginates
Exudate is bound in the center of the fiber and is not bioresorbable
Require secondary dressing
Example - Aquacel®

Hydrogels

Consists of a three dimensional cross-linked structure made up of hydrophilic polymers
Increases moisture content
Produces soothing effect
Available as amorphous gel and sheets
Examples – Intrasite®, Vigilon®

NaCl impregnated dressings

For moderate to high exudates
Hypertonic medium discourages bacterial proliferation
Promotes mechanical and autolytic debridement
Available in sheets or ribbon (for tunnels)
Examples - Mesalt®, Curasalt®

Negative pressure wound therapy - Use of sub-atmospheric pressure to promote contraction, remove excess exudates, reduce edema and increase blood flow

Indicated for deep chronic open wounds, dehisced surgical sites, pressure ulcers, mesh grafts and tissue flaps
Requires trained clinician and is costly
Example – V. A. C. system

Petrolatum impregnated dressings