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Pressure ulcers--management of pressure related tissue damage.



GRADES OF RECOMMENDATION

These Grades of Recommendation have been based on the JBI-developed 2006 Grades of Effectiveness (JBI JBI Java Business Integration (Sun)
JBI Joanna Briggs Institute (Adelaide, SA, Australia)
JBI Joint Battlespace Infosphere
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JBI Jamaica Bauxite Institute
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 2006)

Grade A Strong support that merits application

Grade B Moderate support that warrants consideration of application

Grade C Not supported

Recommendations

* Optimal management requires comprehensive and accurate assessment of wound history, aetiology aetiology

see etiology.
 recurrence and characteristics regarding location, staging, size, base, exudates and condition of surrounding skin (Grade 13)

* Patients with a Grade 1-2 pressure ulcer Pressure ulcer
Also known as a decubitus ulcer, pressure ulcers are open wounds that form whenever prolonged pressure is applied to skin covering bony outcrops of the body. Patients who are bedridden are at risk of developing pressure ulcers.
 should be placed on a high specification mattress or cushion with pressure reducing capabilities and be subject to very close observation of skin changes and a documented repositioning regime. If any deterioration occurs an alternating pressure or CLP 1. CLP - Cornell List Processor.
2. CLP - Constraint Logic Programming.
 system should be implemented (Grade B)

* Patients with Grade 3-4 pressure ulcers should be placed on an alternating pressure or CLP system (Grade B)

* Dressings (such as hydrocolloids) create an environment most optimal for wound healing wound healing Physiology The repair of a wound Steps Inflammation, repair and closure, remodeling, final healing; repair of incisions may be either simple–'clean' wounds with little loss of tissue heal by 'primary intention', or 'dirty' wounds heal by  (Grade B)

* Patients with pressure ulcers should actively mobilise, change their position independently or be repositioned as clinically indicated (Grade B)

Background

The management of pressure ulcers pose a significant problem in acute care and community health settings. There are substantial costs associated with treating an established pressure ulcer, for example in 1993 a 600 bed hospital in the UK estimated the cost of preventing and treating pressure ulcers varied between 600,000 [pounds sterling] and 3 million [pounds sterling] a year. It is estimated that the current annual cost for treating pressure ulcers in the UK is approximately 1.4 [pounds sterling]-2.1 billion, which is equivalent to 4% of the total National Health Service expenditure. Additionally, the patient with a pressure ulcer faces emotional and physical difficulties. They suffer pain, inconvenience, reduced quality of life, and often require extended contact with the health care system. Although prevention of pressure ulcers is optimal, the management of existing pressure ulcers focuses on quality care in the areas of wound dressing, use of appropriate support surfaces, repositioning, nutrition and surgery.

[ILLUSTRATION OMITTED]

Definition of terms

For the purposes of this information sheet the following definitions are used:

Alternating pressure (AP) surfaces--these surfaces mechanically vary the pressure beneath a patient, thereby reducing the duration of the applied pressure

Constant low pressure (CLP)--these surfaces aim to mould around the shape of a patient to redistribute re·dis·trib·ute  
tr.v. re·dis·trib·ut·ed, re·dis·trib·ut·ing, re·dis·trib·utes
To distribute again in a different way; reallocate.
 pressure over a greater surface area

Pressure ulcer--an area of localised localised - localisation  injury to the skin and/or underlying tissue, usually over a long prominence, as a result of pressure or pressure in combination with shear and/or friction (European Pressure Ulcer Advisory Panel 2003)

Objectives

The purpose of this Best Practice information sheet is to provide health care professionals with evidence based recommendations regarding the management of pressure sores.

Grades of Pressure Ulcer

A number of tools have been specifically developed to grade pressure ulcers. The classification system often referred to in the literature and recommended for use was developed by the European Pressure Ulcer Advisory Panel (see Table 1).

Guidelines Concerning Management

Assessment

Managing a patient with an existing pressure ulcer begins with an assessment of the patient entering the health care system. Following a global assessment of the patient, a specific assessment of the pressure ulcer that includes the aetiology and a detailed wound evaluation should be undertaken. The evidence suggests that the existence of a Grade i pressure ulcer is a significant risk factor for the development of a more severe pressure ulcer.

Support surfaces

Pressure relieving support surfaces aim to reduce the amount or duration of pressure between an individual and the support surface and there have been many studies comparing different support surfaces. Due to the many methodological limitations inherent in the studies it is not possible to recommend one support surface over another.

Consensus agreement, however, recommends that any patient with a Grade 1 or Grade 2 pressure ulcer should be placed on a high specification mattress or cushion with pressure reducing capabilities and be subject to very close observation of skin changes and a documented repositioning regime. Furthermore, if any deterioration occurs an alternating pressure or constant low pressure (CLP) system should be implemented. Patients with Grade 3-4 pressure ulcers should be placed on an alternating pressure or CLP system.

Dressing and topical agents

Currently, the literature provides insufficient evidence insufficient evidence n. a finding (decision) by a trial judge or an appeals court that the prosecution in a criminal case or a plaintiff in a lawsuit has not proved the case because the attorney did not present enough convincing evidence.  to indicate which dressings are the most effective in treating pressure ulcers. However, the choice of dressing or topical agent should be based on assessment of skin and ulcer condition, treatment objective, dressing characteristics, previous positive effect of particular dressing, dressing or a topical agent's indications and contraindications for use, risk of adverse events and patient preference.

Dressings that create an environment most optimal for wound healing (eg. hydrocolloids, hydrogels, hydrofibres, foams, films, alginates, soft silicones) should be used in preference to basic dressing types (eg. gauze gauze (gawz) a light, open-meshed fabric of muslin or similar material.

absorbable gauze  gauze made from oxidized cellulose.
, paraffin gauze and simple dressing pads).

The potential positive effects of debridement Debridement Definition

Debridement is the process of removing nonliving tissue from pressure ulcers, burns, and other wounds.
Purpose

Debridement speeds the healing of pressure ulcers, burns, and other wounds.
 in the management of pressure ulcers should be recognised and considered by clinicians.

Antimicrobial agents Antimicrobial agents

Chemical compounds biosynthetically or synthetically produced which either destroy or usefully suppress the growth or metabolism of a variety of microscopic or submicroscopic forms of life.
 

RCTs (randomised Adj. 1. randomised - set up or distributed in a deliberately random way
randomized

irregular - contrary to rule or accepted order or general practice; "irregular hiring practices"
 controlled trials) that focus on the effectiveness of antimicrobial agents were small and generally of poor methodological quality. Therefore there is insufficient evidence to indicate whether antimicrobials are effective in treating pressure ulcers. It is suggested that where patients are exhibiting systemic or clinical signs of infection, antimicrobial antimicrobial /an·ti·mi·cro·bi·al/ (-mi-kro´be-al)
1. killing microorganisms or suppressing their multiplication or growth.

2. an agent with such effects.
 therapy should be considered.

Repositioning

Health care professionals routinely engage in interventions to reduce the effects of impaired mobility on the healing of pressure ulcers. The optimal frequency for this to occur in terms of patient benefit and use of resources, however, is not clear. The literature reports a range of timeframes for repositioning from two hourly to six hourly. Due to the lack of evidence the following recommendations are consensus-based:

* Patients with pressure ulcers should actively mobilise, change their position independently or be repositioned frequently

* Avoid positioning patients directly on pressure ulcers or bony prominences

* Frequency of repositioning should be determined by the individual patient's needs and the following factors should be considered; general health status of the patient, location of the ulcer, general skin assessment and acceptability to the patient.

Nutrition

It has been reported that malnutrition is positive[y correlated with pressure ulcer incidence and severity, however the evidence is inconclusive. The guideline suggested that nutritional support nutritional support,
n the supply of foods and liquids necessary to advance healing and support health.
 should be given to patients with identified nutritional deficiency and any support/supplementation be based on nutritional assessment nutritional assessment Oncology The profiling of a Pt's current nutritional status and risk of malnutrition and cancer cachexia. See Cachexia, Malnutrition.  using a recognised tool, general health status, patient preference and expert dietician dietician Nutritionist A health professional with specialized training in diet and nutrition  and/or specialist input.

Surgery

Surgery is generally reserved to treat Grade 3-4 pressure ulcers. The current surgical management of pressure ulcers consists of debridement, which can be superficial and may or may not include the removal of bone tissue followed by flap coverage. Pressure ulcers can be surgically debrided and left as an open wound to heal, surgically closed with or without debridement or repaired using skin flaps or grafting. The literature consists of case reports, case series and retrospective chart reviews of variable quality. Therefore the effectiveness of surgery and optimal technique for the treatment of pressure ulcers is unclear.

Adjunct therapies

When conventional therapies have failed to make improvements in wound healing, adjunct therapies are being increasingly used.

However, the cost- and clinical effectiveness of many of these treatments have not been rigorously tested.

Topical negative pressure

One small trial with methodological limitations assessed topical negative pressure. The trial suggested that topical negative pressure may increase healing rates of pressure ulcers compared to sterile gauze dressings. The findings, however, must be treated with extreme caution and further research is required.

Electrotherapy electrotherapy /elec·tro·ther·a·py/ (-ther´ah-pe) treatment of disease by means of electricity.

e·lec·tro·ther·a·py
n.
Medical therapy using electric currents.
 and therapeutic ultrasound Therapeutic ultrasound is a technique that uses high-frequency sound waves (ultrasound) to speed healing in injured joint or muscle tissue. The frequency used is typically 1-3 Mhz.  

There is no evidence that electrotherapy or therapeutic ultrasound for the treatment of pressure ulcers is beneficial. However, the possibility of a beneficial or harmful effect cannot be discounted due to the small number of trials with small sample sizes and methodological weaknesses.

Electromagnetic therapy Electromagnetic therapy is a form of alternative medicine which claims to treat disease by applying electromagnetic energy to the body.[1][2] It has been labelled pseudoscientific by its critics.  

A meta-analysis of three trials assessing the effect of electromagnetic therapy demonstrated no benefit. It consisted of only 137 participants and further research is required before definitive recommendations can be made for this particular practice.

Conclusions

The best method of treatment for managing existing pressure ulcers remains unclear, but it is evident that reducing firstly their incidence and secondly, variability in treatment is necessary. Further well-designed, large scale research is required most urgently in the areas of risk of delayed healing/complications to healing, pressure ulcer assessment, support surfaces, use of antimicrobials, nutrition and surgery.

INFORMATION SOURCE

This Best Practice information sheet, which supersedes the JBI information sheet of the same title published in 1997, (JBI, 1997) is based on a clinical practice guideline developed by the Royal College of Nursing The Royal College of Nursing (RCN) is a membership organisation with over 395,000 members in the United Kingdom. It was founded in 1916, receiving its Royal Charter in 1928, Queen Elizabeth II is the patron.  and National Institute for Health and Clinical Excellence “NICE” redirects here. For other uses, see NICE (disambiguation).
The National Institute for Health and Clinical Excellence or NICE is a Special Health Authority of the National Health Service in England and Wales.
 (2005).

In addition this Best Practice information sheet has been reviewed by nominees of International Joanna Briggs Collaborating Centres:

Petra Brysiewicz, South African Centre for Evidence Based Nursing and Midwifery midwifery (mĭd`wī'fərē), art of assisting at childbirth. The term midwife for centuries referred to a woman who was an overseer during the process of delivery. In ancient Greece and Rome, these women had some formal training. , School of Nursing, Faculty of Community and Development Disciplines, University of KwaZulu-Natal Organisation
The University is divided into four colleges, each divided into faculties:
  • The College of Humanities
  • The Faculty of Education
, South Africa South Africa, Afrikaans Suid-Afrika, officially Republic of South Africa, republic (2005 est. pop. 44,344,000), 471,442 sq mi (1,221,037 sq km), S Africa. .

Catherine Edgar, Bundoora Extended Care Centre, Bundoora, Victoria Bundoora is a suburb of Melbourne, Victoria, Australia. The word Bundoora is Aboriginal for "the favourite haunt of the kangaroo". Its Local Government Area is the City of Banyule and the City of Whittlesea. , Australia.

Peter Davis, School of Nursing, Nottingham University, Nottingham, UK.

Prof Samantha Pang, Hong Kong Hong Kong (hŏng kŏng), Mandarin Xianggang, special administrative region of China, formerly a British crown colony (2005 est. pop. 6,899,000), land area 422 sq mi (1,092 sq km), adjacent to Guangdong prov.  Centre EBN EbN
abbr.
east by north

Noun 1. EbN - the compass point that is one point north of due east
east by north
, Chinese University of Hong Kong The motto of the university is "博文約禮" in Chinese, meaning "to broaden one's intellectual horizon and keep within the bounds of propriety". , Hong Kong Special Administrative Region A special administrative region may be:
People's Republic of China
  • Special administrative regions, present-day administrative divisions (as of 2006) set up by the People's Republic of China to administer Hong Kong (since 1997) and Macau (since 1999)
.

REFERENCES

Pearson, A., Wiechula, R., Court, A. and Lockwood, C. 2005, The JBI model of evidence-based healthcare. International Journal of Evidence-Based Healthcare 2005. 3(8):207-215.

The Joanna Briggs Institute. 1997. Pressure Sores--Part 2: management of pressure related tissue damage. Best practice: evidence-based practice information sheets for health professionals. 1(2):1-6.

The management of pressure ulcers in primary and secondary care. A clinical practice guideline. 2005. Royal College of Nursing and National Institute for Health and Clinical Excellence.

The Joanna Briggs Institute, Systematic reviews--the review process, levels of evidence. Available at: http://www.joannabriggs.edu,au/pubs/approach.php (accessed 2006).

This Best Practice information sheet presents the best available evidence on this topic. Implications for practice are made with an expectation that health professionals will utilise this evidence with consideration of their context, their client's preference and their clinical judgement. (Pearson et al 2005)

The Joanna Briggs Institute Margaret Graham Building, Royal Adelaide Hospital The Royal Adelaide Hospital is Adelaide's largest hospital with over 700 beds. Founded in 1840, the Royal Adelaide provides tertiary health care services for South Australia and provides secondary care clinical services to residents of Adelaide's inner city. , North Terrace, South Australia South Australia, state (1991 pop. 1,236,623), 380,070 sq mi (984,381 sq km), S central Australia. It is bounded on the S by the Indian Ocean. Kangaroo Island and many smaller islands off the south coast are included in the state. , 5000 www.joannabriggs.edu.au ph: +61 8 8303 4880 fax: +61 8 8303 4881 email: jbi@adelaide.edu.au

Published by Blackwell Publishing

Also available on JBI CONNECT (Clinical On-line Network of Evidence for Care and Therapeutics) http://www.jbiconnect.org.

The procedures described in Best Practice must only be used by people who have appropriate expertise in the field to which the procedure relates.

The applicability of any information must be established before relying on it. While care has been taken to ensure that this edition of Best Practice summarises available research and expert consensus, any loss, damage, cost, expense or liability suffered or incurred as a result of reliance on these procedures (whether arising in contract, negligence or otherwise) is, to the extent permitted by law, excluded.
Table 1. Classification of pressure ulcer severity

Grade I     Non-blanchable erythema of intact skin.
            Discolouration of the skin, warmth, oedema,
            induration or hardness may also be indicators,
            particularly on individuals with darker skin.

Grade II    Partial thickness skin loss involving epidermis,
            dermis or both. The ulcer is superficial and presents
            clinically as an abrasion or blister.

Grade III   Full-thickness skin loss involving damage to or
            necrosis of subcutaneous tissue that may extend
            down to, but not through underlying fascia.

Grade IV    Extensive destruction, tissue necrosis or damage to
            bone, muscle or supporting structures with or
            without full-thickness skin loss.
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Title Annotation:CLINICAL UPDATE
Publication:Australian Nursing Journal
Geographic Code:8AUST
Date:Jun 1, 2008
Words:1902
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