- WOUND CARE NURSING SPECIALTY

Report
Pressure Ulcers
Assessment and
Management
By
Alex Khan RN BSN CWCN CFCN
Jesse Lewis RN BSN CWCN
DEVELOPED FOR
Pressure Ulcer Assessment and Management
OBJECTIVES
By the end of the course participants will be able to:
 Classify pressure ulcers by stage and differentiate ulcers of
non-pressure etiology.
 Discuss current treatment practices and interventions for
pressure ulcer management.
Overview: Layers of the skin
The skin is comprised of three major components:
 Epidermis
 Dermis
 Subcutaneous tissue
Though interrelated, each layer of skin has different structures, cell
types and functions.
What are Pressure Ulcers?
Localized areas of tissue necrosis which develop
when soft tissue is compressed between a bony
prominence and an external surface for a prolonged
period of time.
Most pressure ulcers occur over bony prominences,
where combined with friction and shearing forces
result in skin breakdown.
Several factors other than pressure contribute to
ulcers including moisture, friction, shear, immobility,
sensory loss and some underlying medical conditions.
Common Pressure Ulcers sites
Supine:
23% sacro-coccygeal
8% heels
1% occiput; spine
Sitting:
24% ischium
3% elbows
Lateral:
15% trochanter
7% malleolus
6% knee
3% heels
Classification of Pressure Ulcers
The staging of pressure ulcers, as defined by national
guidelines (NPUAP, CMS), allow for common
understandings for healthcare professionals. The
staging of a pressure ulcer reflects the amount of
tissue damage.
 STAGE I
 STAGE II
 STAGE III
 STAGE IV
 SUSPECTED DEEP TISSUE INJURY (DTI)
 UNSTAGEABLE
Stage I Pressure Ulcer
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.
Management of Stage- I
Pressure Ulcers
Stage I on Trunk of the Body –
 Manage incontinence, keeping area
clean and dry.
 Use moisture barrier cream PRN.
 Off load area of pressure ulcer with
pressure reducing / distribution surface and
turning and repositioning schedule.
Stage I on Heels –
 Ensure that heel(s) are floated at all
times with frequent monitoring.
Stage II Pressure Ulcer
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.
Management of Stage- II
Pressure Ulcers
Dry Wound Bed
 Cleanse with normal saline, apply small
amount of hydrogel and cover with non
adherent dressing, change every day.
Off load area of pressure ulcer with pressure
reducing / distribution surfaces and turning and
repositioning schedule.
Minimal Drainage
Cleanse with normal saline, apply
hydrocolloid dressing every three days and
PRN soiling or dislodging. Monitor placement
every day.
Stage III Pressure Ulcer
Full thickness tissue loss. Subcutaneous fat may be visible but bone,
tendon or muscles are not exposed. Slough may be present but does not
obscure the depth of tissue loss. May include undermining and tunneling
Management of Stage- III
Pressure Ulcers
Minimal Drainage and Clean Wound Bed
Cleanse with normal saline, apply small amount of
hydrogel and cover with non adherent dressing
change every day.
Off load area of pressure ulcer with pressure
relieving / distribution surface and turning and
repositioning schedule.
Presence of Slough with drainage
 Sharp debridement / Enzymatic debridement
Use Foam or Calcium Alginate dressing for
moderate to copious drainage management.
 Slough 30% or less in the wound, negative
pressure wound therapy is preferred treatment.
Stage IV Pressure Ulcer
Full thickness tissue 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.
Management of Stage- IV
Pressure Ulcers
Minimal Drainage and Clean Wound Bed
Cleanse with normal saline, apply hydrogel and
cover with non adherent dressing change every day.
Off load area of pressure ulcer with pressure
relieving surface and turning and repositioning
schedule.
Presence of Slough with drainage
 Sharp debridement / Enzymatic debridement
Use Foam or Calcium Alginate dressing for
moderate to copious drainage management.
 Slough 30% or less in the wound, negative
pressure wound therapy is preferred treatment.
 Tunneling and undermining shall be filled
appropriately.
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.
Management of Suspected
Deep Tissue Injury
Cleanse with normal saline, apply foam
dressing change every day.
Off load area of pressure ulcer with
pressure relieving / distribution surface and
turning and repositioning schedule.
Use Foam dressing for drainage
management.
 Castor oil / Balsam / Peru / Trypsin spray
is the preferred treatment.
Un-stageable Pressure Ulcer
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. Base of the wound cannot be visualized.
Management of Un-stageable
Pressure Ulcers
Cleanse with normal saline, apply hydrogel and
cover with non adherent dressing change every
day.
Off load area of pressure ulcer with pressure
relieving / distribution surface and turning and
repositioning schedule.
Use Foam dressing for drainage management.
 Castor oil / Balsam / Peru / Trypsin spray is
the preferred treatment for wounds with Intact
eschar.
 Sharp or enzymatic debridement for the
management of slough.
Causative Factors for the Development of
Pressure Ulcers
 Immobility or limited mobility
 Bowel & Bladder Incontinence
 Shearing and friction injuries
 Advanced age
 Malnutrition or debility
 Obesity
 History of pressure ulcers
 Dehydration
 Contractures
 Use of orthotic devises or restraints
 Lack of compliance
 Use of diapers / excess skin moisture
Pressure Ulcer Prevention / Nursing Interventions
 Turn every 2 hours (q2h) Schedule: e.g. alternating positions Right/Back/Left q2h. May
place pillow under one hip at a time if patient cannot tolerate full turning.
 Maximal Remobilization: Passive range of motion, physical therapist (PT) consult to
plan appropriate measures for patient. Spinal Cord Injury and Disorder (SCI&D) patients (or
any patient with custom chairs) are to sit in their own wheelchairs and cushions only.
 Protect Heels: Support entire leg with pillows to allow heels to suspend above the
mattress or use heel protectors. Assess heels everyday for signs of pressure. Consider
pressure relieving / distribution bed surface.
 Manage Moisture: Correct cause, (e.g., diarrhea), reduce or eliminate incontinent
episodes (e.g., bladder training); Use mild soap, rinse, and dry skin well and apply moisture
barrier cream. No diapers while patient in bed.
 Manage Nutrition: Increase protein intake more than 100% RDA, if not renal or liver
impaired. Dietary consult to determine dietary needs and/or effectiveness of tube feedings.
 Reduce Friction and Shear: Use bed trapeze or pull sheet for lifting and moving patient
up in bed. Apply transparent film or hydrocolloid dressing (Duoderm) over friction areas
(e.g., elbows) Keep the head of the bed less than 30 degrees as often as possible.
References
Myers, B.A. (2004). Wound Management: Principles and Practice.
Prentice Hall: Upper Saddle River, New Jersey, 37-45, 369-391.
National Pressure Ulcer Advisory Panel (NPUAP).
www.npuap.org.

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