Telephone-Based Training

Pressure Ulcer Management

Dial-In Information
Telephone Number: (888) 850-5066
Confirmation Code: 35193
Pressure Ulcer Assessment
and Management
Presented by:
Beth Brizee, RN,C
Director of Clinical Operations
TriLine Medical
888-966-6662 ext 301

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 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.
† Review key documentation areas for the medical record
management of pressure ulcers.

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Overview of the 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

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What is a Pressure Ulcer?
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.
Unlike other ulcerations, which have a disease process associated
with their development or decline, pressure ulcers have
heightened requirements around: risk assessment; proactive
and therapeutic care giver interventions; assessment of
response to interventions and medical record management.
Most pressure ulcers occur over bony prominences, where
combined with friction and shearing forces result in skin
breakdown.
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Most common sites in bed-
bound elderly
Supine:
23% sacrococcygeal
8% heels
1% occiput; spine
Sitting:
24% ischium
3% elbows
Lateral:
15% trochanter
7% malleolus
6% knee
3% heels
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Classification of Wounds
The staging of pressure ulcers, as defined by national guidelines
(NPUAP, CMS, AHCPR), allow for common understandings
for healthcare professionals. The staging of a pressure ulcer
reflects the amount of tissue damage. Outside of the MDS,
only pressure ulcers are staged – stage I – IV, UTD and DTI.

Any wound such as a pressure ulcer, neuropathic ulcer, etc., can

be considered “partial thickness” or “full thickness”
depending upon the amount of tissue involved.

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Pressure Ulcers

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Stage I Pressure Ulcer
The ulcer appears as a defined area of persistent red, blue, or
purple hues in lightly pigmented skin.
In darker skin tones, the ulcer may appear with discoloration,
warmth, edema, induration or hardness.

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Stage I Pressure Ulcer Treatment Options
Stage I on Trunk of the Body –
… Manage incontinence, keeping area clean and dry.
… Use moisture barrier as needed.
… Off load area were pressure ulcer is – pressure reducing surfaces

Stage I on Heels –
… Ensure that heel(s) are floated at all times with frequent monitoring.

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Stage II Pressure Ulcer
Partial thickness skin loss involving epidermis, dermis, or both.
The ulcer is superficial and presents clinically as an abrasion,
blister, or shallow crater.

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Stage II Pressure Ulcer Treatment Options
Dry Wound Bed –
… Cleanse with normal saline, apply small amount of hydrogel and cover
with dd every day.
… Off load area were pressure ulcer is – pressure reducing or relieving
surfaces.

Minimal Drainage –
… Cleanse with normal saline, apply hydrocolloid dressing every three days
and prn soiling or dislodging. Monitor placement every day.
… Off load area were pressure ulcer is – pressure reducing or relieving
surfaces.

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

The ulcer presents clinically as a deep crater with or without

undermining of adjacent tissue.

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Stage III Pressure Ulcer Treatment Options
Minimal Drainage and Clean Wound Bed –
… Cleanse with normal saline, apply small amount of hydrogel and cover
with dd every day.
… Off load area were pressure ulcer is – pressure relieving surfaces.
Presence of Slough –
… Cleanse with normal saline, apply Accuzyme and cover with dd every
day.
… Use Foam dressing instead of dd for heavy drainage.
… Off load area were pressure ulcer is – pressure relieving surfaces.
Heavy Drainage and Clean–
… Cleanse with normal saline, apply foam dressing every two days and prn
soiling or dislodging. Monitor placement every day.
… Off load area were pressure ulcer is – pressure relieving surfaces –
preferable a low air loss mattress replacement. 13
Stage IV Pressure Ulcer
Full thickness skin loss with extensive destruction, tissue
necrosis, or damage to muscle, bone, or supporting structures
(e.g., tendon, joint capsule).
Undermining and sinus tracts also may be present.

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Stage IV Pressure Ulcer Treatment Options
Minimal Drainage and Clean Wound Bed –
… Cleanse with normal saline, apply small amount of hydrogel and cover
with dd every day.
… Off load area were pressure ulcer is – pressure relieving surfaces –.
Presence of Slough –
… Cleanse with normal saline, apply Accuzyme and cover with dd every
day.
… Use Foam dressing instead of dd for heavy drainage.
… Off load area were pressure ulcer is – pressure relieving surfaces –
preferable a low air loss mattress replacement.
Heavy Drainage and Clean–
… Cleanse with normal saline, apply foam dressing every two days and prn
soiling or dislodging. Monitor placement every day.
… Off load area were pressure ulcer is – pressure relieving surfaces – 15
preferable a low air loss mattress replacement.
UTD (Unable to Determine Stage)
Pressure Ulcer
When a pressure ulcer wound bed is covered with non-viable
tissue such as “slough” or “eschar” the pressure ulcer can not
be staged as visualization of the amount of tissue damage /
involvement is impossible.

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UTD Stage Pressure Ulcer
Treatment Options
Presence of Slough –
… Cleanse with normal saline, apply Accuzyme and cover with dd every
day.
… Use Foam dressing instead of dd for heavy drainage.
… Off load area were pressure ulcer is – pressure relieving surfaces –
preferable a low air loss mattress replacement.
Heavy Drainage and Clean–
… Cleanse with normal saline, apply foam dressing every two days and
prn soiling or dislodging. Monitor placement every day.
… Off load area were pressure ulcer is – pressure relieving surfaces –
preferable a low air loss mattress replacement.
Note – intact eschar on the lower extremities (i.e. heels) should not be
actively debrided but should have pressure managed – floating of the
heels 17
Deep Tissue Injury
These wounds present as intact skin with dark purple shading
almost to black area usually within a reddened area of
skin. This represents a pressure injury of an unknown depth
so this wound cannot be staged – also known as “Purple
Pressure Injury” or “Pre-Eruptive Full-Thickness Pressure
Ulcer.”

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Causative Factors for the Development
of Pressure Ulcers
† Immobility or limited mobility
† Incontinence
† Shearing and friction injuries
† Advanced age
† Malnutrition or under-nutrition
† Significant obesity or thinness
† History of pressure ulcers
† Dehydration
† Contractures
† Use of orthotic devises or restraints
† Issues of resident compliance

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Immobility and Pressure Ulcers – CMS
Statements
Some statements around tissue load management from CMS:

† “Repositioning is a common, effective intervention for an

individual with a pressure ulcer or who is at risk of
developing one.”

† “Repositioning is critical for a resident who is immobile or

dependent upon staff for repositioning.”

† “Positioning the resident on an existing pressure ulcer should

be avoided since it puts additional pressure on tissue that is
already compromised and may impede healing.”

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Immobility and Pressure Ulcers – CMS
Statements
† “Depending on the individualized assessment, more frequent
repositioning may be warranted for individuals who are at
higher risk for pressure ulcer development or who show
evidence (e.g., Stage I pressure ulcers) that repositioning at
two hour intervals is inadequate.”

† “Based upon an assessment including evidence of tissue

tolerance while sitting (checking for Stage I ulcers as noted
above), the resident may not tolerate sitting in a chair in the
same position for one hour at a time and may require a more
frequent position change.”

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Interventions for the Management
of Immobility
† Individualized re-positioning schedules with thorough
communication of needs and expectations
† Use of appropriate pressure relieving or reducing support
surfaces
† Float heels
† Keep sheets free from wrinkles
† Avoid raising the head of bed more than 30 degrees
† As appropriate, perform active or passive range of motion
exercises to relieve pressure and promote circulation
† Adjust or pad appliances, casts, or splints as needed to ensure
a proper fit and to prevent pressure and impaired circulation
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Interventions for the Management
of Incontinence
† Implement as appropriate a bowel and bladder retraining
program
† Ensure healthful hydration through adequate daily fluid
intake
† Assess environmental issues – accessibility, manual dexterity
(how easily can the resident manipulate their clothing)
† Regular reminders to void with prompt response to toilet
† Fiber rich diets
† Promote regular exercise
† Maintain effective hygiene care, cleaning the perineal area
frequently with use of a moisture barrier
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Shearing and Friction
Shear -
… The gravitational pull of the body downward while the
skin stays stationary on the surface of bed or chair.
… This gravitational pull creates a change in the angle of
capillaries.

Friction –
… Result from forces that tend to cause two opposing
surfaces to slide and displace against each other.

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Shearing Injury

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Interventions for the Prevention of
Shear and Friction Injuries
Assuring that individuals are being repositioned and that
nursing staff understand:
… Use of proper transferring and positioning equipment

… Teaming up to safely reposition residents

… Limit HOB elevation

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Interventions for the Management
of Malnutrition “Under-Nutrition”
† RD assessment and recommendations – should be at least
every month if a pressure ulcer is present
† Monitoring intake and output with communication of any
changes in patterns
† Provide needed dental care
† Follow prescribed diets – protein supplementation, thickened
liquids
† Offer liquids as appropriate at each care giving activity
† Encourage intake
† Maintain accurate medical record information for MD and
RD – weights and I/O’s
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Overview of General Treatment
Interventions for Pressure Ulcers
General considerations for the treatment of pressure ulcers:
† Manage the moisture.
† Remove non-viable tissue.*
„ Enzymatic
„ Sharp debridement
„ Mechanical debridement
† Tissue load management – never placing resident directly on
an existing wound – use appropriate support surfaces.
† Protect the peri-wound tissue.

*Intact eschar on extremities should not be debrided in most cases

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Classification of Wounds –
Federal Guideline Statement
At the time of the assessment, clinicians (physicians, advance
practice nurses, physician assistants, and certified wound care
specialists, etc.) should document the clinical basis (for
example, type of skin injury/ulcer, location, shape, ulcer
edges and wound bed, condition of surrounding tissues) for
any determination that an ulcer is not pressure related,
especially if the injury/ulcer has characteristics consistent
with a pressure ulcer, but is determined not to be one.”

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 Arterial Ulcerations
Venous Stasis Ulcerations
Neuropathic Ulcerations

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Arterial Ulcerations
Cause – Inadequate circulation to the legs
† Contributing Factors:

„ Arteriosclerosis and atheroslerosis

„ Micro thrombi
„ Smoking
„ Elevated cholesterol and lipids
„ Hypertension
„ Diabetes

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Arterial Ulcerations Clinical Presentation
† Small, deep, punched out lesions
† Well demarcated, smooth edges
† Often contain necrotic tissue and / or pale wound beds
† Ulcers frequently appear on tips of toes or fingers and over
phalangeal heads
† Ulcers may also appear around heels and ankles, sides and
plantar surface of the foot

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Treatment Interventions for
Arterial Ulcers
The only treatment for arterial ulcerations is surgical intervention,
re-establishing circulation. Many of our LTC residents are
not surgical candidates. In this case make sure to have the
MD document the fact that the benefits of vascular surgical
intervention are out weighed by the risk of the procedure. It
is also important to have the resident (if appropriate) and the
family members understand this as well.

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Venous Stasis Ulcerations
† Affect 3.5% of the population
† Have approximately 70% recurrence rate
† Anatomy and Physiology of Venous Stasis Ulcers
„ Incompetent, malfunctioning valves:
Contribute to backflow
Result in increased pressure within veins
Allow leakage of serum and blood cells into tissue
Create edema
Presents with hemosiderin staining
Ulcerations

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Venous Stasis Ulcerations
Clinical Presentation
… Superficial
… Irregular in shape
… Usually not painful / sensitive
… Usually occur on medial aspect of leg
… Brawny edema, deep, ruddy red tissue
… Legs appear hard and wooden-like
… Often heavily draining ulcers

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Treatment Interventions for
Venous Stasis Ulcers
The treatment for venous stasis ulcers is surgical repair of the
malfunctioning valves. As with arterial ulcerations, many of
our LTC residents are not surgical candidates. In this case
make sure to have the MD document the fact that the benefits
of vascular surgical intervention are out weighed by the risk
of the procedure. It is also important to have the resident (if
appropriate) and the family members understand this as well.

Also note, that it is very important to ensure that arterial

insufficiency has been ruled out before elevating or applying
compression therapy.
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Diabetic Neuropathic Ulcer
† Requires that the resident be diagnosed with diabetes mellitus
and have peripheral neuropathy.

† The diabetic ulcer characteristically occurs on the foot, e.g.,

at mid-foot, at the ball of the foot over the metatarsal heads,
or on the top of toes with Charcot deformity.

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 Medical Record
Documentation for
Wound Care

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Medical Record Risk Management
for Pressure Ulcers
† Unlike other ulcerations, which have a disease process
associated with their development or decline, pressure ulcers
have heightened requirements around: risk assessment;
proactive and therapeutic care giver interventions; assessment
of response to interventions and medical record management
„ Risk Assessment
„ MD notification / participation in plan of care
„ Actual and Potential care plans
„ IDT interventions and notes
„ Treatment records with response to interventions

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Assessment Parameters
† Wounds need to have the following assessed:
„ Etiology – if not pressure then the MD should document as well
„ Stage if pressure
„ Size – length by width by depth and tunneling if present
„ Wound bed tissue characteristics
„ Periwound tissue characteristics
„ Signs and symptoms of infection
„ Response to current interventions

† It is imperative that all wounds be assessed:

„ Immediately upon admission
„ At least weekly
„ Upon change of wound status (improvement or decline)
„ Upon discharge

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Miscellaneous Discussion
Points on Wound Healing
† “Healed” vs. “Re-surfaced”
† Tensile strength at end of proliferation phase and the
remodeling phase
† Regulatory risk of re-occurrence
† Assessment of scar tissue

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Closing Questions and
Comments

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Quality Improvement Resources

ƒ Lumetra
www.Lumetra.com
ƒ Advancing Excellence Campaign
http://www.nhqualitycampaign.org/
ƒ MedQIC
www.medqic.org
 Setting Targets – Achieving Results
(STAR)
ƒ A password-protected Web site created for
nursing homes
ƒ View current performance trends for six Quality
Measures (QMs):
High-risk pressure ulcers
Post acute pressure ulcers
Chronic care pain
Post acute pain
Depression
Physical restraints
ƒ Set annual performance targets.
ƒ Set your QM targets at www.nhqi-star.org.
To Get Your CEU Credit

Download the CEU Evaluation Form.

ƒ Go to www.lumetra.com/events. Scroll down and click on
the link for the 02/15/07 – Pressure Ulcer Management
teleconference to download the CEU evaluation form.
ƒ Complete the form.
Legibly
Include License number.
Fax the completed form to (415) 677-2091.
ƒ A CEU certificate will be mailed to you.