Pressure ulcers: current treatment trends.

Decubiti are too debilitating, too expensive and too frequent in the nursing home. Here's how to control them.

In a world where medical advances and technological breakthroughs abound, pressure ulcers still remain a serious problem. It is estimated that over one million people have pressure ulcers. Their prevalence in long-term care has been documented as high as 45%. Thirty-five to 60% of residents admitted to long term care facilities have pressure ulcers upon admission. The cost of pressure ulcer care, per patient, has been estimated between $15,000 and $86,000. These staggering numbers will continue to rise as the population lives longer.

In reality, most pressure ulcers are preventable. The key is to provide the correct preventive products and techniques to the resident upon admission to the facility. Despite one's best efforts, though, a pressure ulcer may still develop. It is then health care team's responsibility to provide appropriate treatment to assist the wound healing process.

There is not a universal protocol for wound care that meets the needs of all patient populations. Caregivers must first critically assess the wound in order to design an appropriate plan of care for each patient. This task may sound easy, but in fact it is not. There are many different topical wound care products, support surfaces and dietary supplements, as well as other adjunctive products that assist in wound healing. Certain guidelines have been established in choosing the correct modalities.

Back To Basics 

A basic understanding of the skin is essential prior to assessing a patient's wound. First, note that the skin is the largest organ of your body. It makes up ten percent of your body's weight and covers approximately two square yards of an adult. The skin is essentially made up of two layers: the epidermis and the dermis. The epidermis is the outermost layer of your skin. It is thin, avascular and regenerates every four to six weeks. The epidermis maintains skin integrity, acting as to barrier to toxic agents, dirt, bacteria and microorganisms. The epidermis is made up of five sublayers.

Beneath these is the dermis, which provides support, blood, and oxygen to the epidermis. The dermal layer contains hair follicles, sweat glands, sebaceous glands, blood vessels, nerves and lymphatics. The dermis is made up of collagen and elastic fibers that give the dermis its strength. The thick bundles of collagen anchor the skin to the subcutaneous tissue fascia, muscle and bone.

Pressure ulcers are usually classified using a staging system. There are many staging systems from which to choose. But one has to remember that staging is only an anatomical description of depth -- one parameter used when describing the wound. It is critical that the caregiver continue to accurately document the length, width and depth using consistent measurements, such as centimeters. Also important are the color of the wound bed, the peri-wound skin, drainage and odor. However, the use of a staging system does provide your facility with consistent vocabulary for documentation and reimbursement.

When you are assessing a pressure ulcer, you should consider the local and systemic factors that affect the wound healing process. Local factors are those that occur directly at the wound site. These may include pressure, trauma, a dry environment, infection and/or edema that can cause tissue necrosis. Systemic factors occur inside the body and may play a role in impeding the wound healing process. Examples of systemic factors are:

* age * body build * chronic diseases * diabetes * nutrition * oxygen supply * steroids * stress

After identifying the appropriate factors influencing a resident's case, the health care professional must then customize a plan of care accordingly.

A Risk Assessment Tool

Many pressure ulcers can be prevented by identifying those patients at risk for skin breakdown when they are admitted to the facility. A reliable risk assessment tool should be implemented upon admission and whenever a patient's status changes. The goal of the risk assessment tool is to assess each patient for potential or actual skin breakdown and to ensure that proper standards of care are implemented for the prevention, early intervention and treatment of pressure ulcers and/or wounds.

Support Surface Selection

All patients at risk or with existing pressure ulcers must, on admission to the facility, be placed on a pressure-reducing or -relieving device to prevent or treat pressure ulcers. A pressure-reducing device reduces pressures below those produced by a standard hospital mattress, but not consistently. This is why a need has been documented for a turning schedule to be used with a pressure-reducing device. Turning schedules should be used in conjunction with all support surfaces, chair cushion and mattress overlays. Remember, too, that we turn patients for other reasons than to relieve pressure -- for example, to prevent pulmonary and GU complications.

It has been well documented that 2" convoluted foam mattress and chair overlays only provide comfort; they are not effective in reducing or relieving pressure. There are many such support surfaces from which to choose. There is not one universal chair or mattress overlay effective for all populations. Caregivers must choose individual products carefully depending on the resident's situation.

Wound Care Products

The use of certain wound care products, such as Maalox and heatlamps, has been passe since Dr. George Winters and other researchers demonstrated that wounds heal three to five times faster in a moist environment than in a dry one.

To date, there are over 2000 wound care products on the market. The choices for topical wound care products can be overwhelming. In order to understand the product usage, categorizing dressing materials generically is critical. Looking at each generic category, the caregiver must understand the actions, indications and contraindications of the product (just like oral medications) prior to applying the dressing. Remember, you can do just as much harm if you apply the incorrect topical medication as you can by giving a resident the wrong oral medication.

One must keep in mind that every resident is an individual and deserves individual treatment options. The use of rigid treatment protocols is not in the best interest of the resident.

Conclusion

Many educational resources are published to assist the healthcare professional in updating his/her knowledge related to wound care. Currently available TABULAR DATA OMITTED are printed reference guides for the clinician (as well as patient information brochures) entitled Guidelines for the Prediction and Prevention of Pressure Ulcers, which were designed by the Agency for Health Care Policy (AHCPR). The AHCPR is a branch of the U.S. Department of Health and Human Services. To obtain a copy of the published guidelines,you may write to or call:

Treatment guidelines for the more advanced pressure ulcers are scheduled for publication next year.

Another multidisciplinary panel of experts, called the National Pressure Ulcer Advisory Panel (NPUAP), was formed in 1987. Their mission is to provide "leadership for improved outcomes in pressure ulcer prevention and management through education, legislation and research."

Use all of your resources -- journals, textbooks, videos, healthcare professionals -- that provide expertise in wound care. Remember, the use of educational tools creates a vital link between the caregiver and the resident.

For appropriate prevention and management of pressure ulcers, collaborative practice is essential with the resident's primary physician and facility staff, including the nurse, dietician, physical therapist, occupational therapist, wound care specialist (if available), purchasing director and (when possible) the resident.

Ongoing evaluation of the topical treatment, support surface and dietary needs is paramount. You may use an evolution of wound care products as the wound heals, but understanding their actions, indications and contraindications is essential. Specific protocols will not provide the optimal care for patients. Continually updating the education of healthcare professionals regarding prevention and wound healing is the first line of defense against pressure ulcers.

Bibliography

The National Pressure Ulcer Advisory Panel. Pressure ulcers: Prevalence, cost and risk assessment. Consensus Development Conference Statement. Decubitus 1989; 2:24.

Hemphill BH. Time saving assessment and documentation tools that relieve pressure (for patients and staff). In: Krasner D (ed), Chronic Wound Care: A Clinical Source Book For Healthcare Professionals. King of Prussia, PA, Health Management Publications: 117-123.

Melcher RE, Longe RL, Gelbart AO. Pressure sores in the elderly: A systematic approach to management. Postgrad Med 1988; 83: 229.

Steinberg J. Prevalence of decubitus ulcers: Issues of concern. Decubitus 1989; 2:50.

Winkler J. The management of the pressure ulcer population in an extended care setting. In: Chronic Wound Care: A Source Book for Healthcare Professionals. King of Prussia, PA, Health Management Publications: 170-175.

Cathy Thomas-Hess, RN, BSN, CETN, is the ET Nurse Consultant for Manor Health Care Corp., Silver Spring, MD. In addition to her consulting work, she speaks and writes on wound care in various national forums and publications. She is the author/narrator of the video/workbook Fundamentals of Successful Wound Healing: An Educational Approach for the Quality Caregiver.