Policy and Procedure for Pressure Ulcer Assessment and Treatment

Raye Moore

 

 

 

     Wound and skin care for inpatients of any age is important to enhance their recovery and ability to return to their normal lives. The patient must be assessed upon admission. Daily assessments of any skin problems or wounds should be completed to determine what kind of wound is present, so the proper treatment may begin.  Each facility must have a wound and skin care protocol and a wound management training program to ensure all staff are caring for the patient in the proper way to aid the healing process.

       According to Kwong, Pang, Aboo, and Law (2009), pressure ulcer may cause the patient unnecessary pain, a slower recovery from their illness, and incur unwanted costs to the facility.  Some aged adults are at a higher risk of developing a pressure ulcer because of the degree of their illness, cognitive impairment, and a lack of their ability to perform their daily living activities. Some illnesses that have a higher risk of pressure ulcer development are those diagnosed with Parkinsonís disease, heart failure, stroke, Alzheimerís disease, and a compromised respiratory system. Kwong, et al. conducted a study in four private for profit nursing homes in Hong Kong Island to determine what factors predisposed the elderly to acquire pressure ulcers. Three hundred forty-six patients were included in this study, 37.28% were male, and 62.72% were female and were between the ages of 65 and 100 years old.  This study suggested that bedfast and chair fast residents with renal failure or stroke were at the highest risk of developing a pressure ulcer. This study also suggested that most pressure ulcers are preventable if the correct documentation is presented upon admission and daily for seven days.

      According to Zulkowiski and Gray-Leach (2009), pressure ulcers are caused by any unrelieved pressure on body parts, mainly bony prominences, which cause underlying tissue damage. The treatment of pressure ulcers is determined by staging. The first noticeable sign of a developing pressure ulcer is Stage I. In this stage, the skin may be reddened, painful, firm or soft, and resembles minor sunburn and the color and temperature of the area may be warm to the touch. Stage II ulcers present as an opening in the skin with a pink wound bed. It involves the epidermal layer, but not through to the dermal layer. In this stage, there is not slough or eschar present, Zulkowski and Gray-Leach reported Stage III ulcers present as a loss of subcutaneous fat tissue and slough is present. Slough may be yellow, tan, gray, green or brown in color. Stage IV ulcers are full tissue loss with bone, tendons, or muscle visible upon assessment with slough or eschar present. Eschar is brown, tan, or black in the wound bed. When the pressure ulcer is unstageable, the ulcer is covered with slough and eschar in the wound bed and conceals the depth of the wound (Zulkowski & Gray-Leach).

      The Braden Scale was developed by Braden & Bergstrom (1998) to aid in the assessment of patients at risk for developing pressure ulcers. It is the most widely used tool in hospitals and long term care facilities.  The Braden scale includes six different assessment areas to use as a tool to determine if the patient is at risk for developing pressure ulcers. These areas include the patientís sensory perception, moisture risk, activity, mobility, nutrition, and their possibility of friction and shear. Each patient is rated from one to four in each area. The higher the score, the less risk the patient is for developing a pressure ulcer. Patients with a score of 16 or less are considered a high risk for developing a pressure ulcer. Assessment with the Braden scale should be completed daily for the first forty-eight hours, and then weekly until discharge (Braden & Bergstrom, 1998).

       The purpose of this study is to revise an old policy at a local extended care facility using evidence from current literature to improve the treatment and prevention of pressure ulcers. The new policy will help nurses and other patient care staff determine which patients are at risk of developing pressure ulcers. This policy will also help all staff be able to treat patients efficiently and effectively, within their scope of practice, preventing further damage and decreasing their hospital stays.

 

Literature Review

       An online literature review was conducted using OVID Nursing, the key words pressure ulcer prevention and treatment, tools to stage pressure ulcers and products to treat pressure ulcers. Nine hundred articles were retrieved from 1998 to 2012. Of these nine hundred articles, twenty-seven were included in the research. The articles were narrowed down by appropriateness and were all within a seven year time span dating back from 2012. One exception to the timeline is Braden (1998), because of the classic nature of the research related to pressure ulcer prevention.

       Tescher, Branda, Bryne, & Naessens (2012) conducted a study from January to December 2007 at the Mayo Clinic in Rochester, Minnesota to determine which patients were at risk for developing pressure ulcers during their admission and included two acute care hospitals with patients in the Intensive Care Unit (ICU) and Progressive Care units (PCU). There were ten ICU units and seven PCU units included in this study with a total of 12,566 patients in the study.  The study was approved by Mayo Clinicís institutional review board. Patients were over the age of 18 upon admission, had at least one Braden score of 16 or less during their admission, and were released from the hospital during the year 2007.  The staff nurses documented the Braden scale and assessed the patientís skin condition daily during their admission. The medical records of these patients were then examined to determine which patients were at risk for developing a pressure ulcer. A multivariate analysis was conducted to achieve the results and variables with a P value of <.05 was used to determine the results. The results suggested that 416 of the patients developed stage III and stage IV pressure ulcers. Sixty-percent of the patients with a Braden score of 6 to 9 developed a pressure ulcer during their admission and 9% of patients with a score of 10 to12 developed pressure ulcers. The Braden Scale in this study encouraged more in-depth assessments of patients in these units and a low score on this scale will alert nurses to provide the appropriate interventions upon admission. This study suggested that keeping the head of the bed elevated at 30 degrees is an intervention that will decrease the likelihood of patients in the ICU or PCU of developing a pressure ulcer during their admission by minimizing the friction and shear on the coccyx area (Tescher et al., 2012).

      Rapp et al., (2010) conducted a study in sixty-eight nursing facilities in Harris County Texas to determine if the current prevention and treatment of pressure ulcers was adequate. The Director of Nursing of each facility received information on the survey and was compensated five dollars at the time the survey was received.  Forty-three nursing facilities agreed to participate in the survey. Areas studied in the survey included pressure ulcer prevention, assessment of the patientís skin, the patientís risk of developing a pressure ulcer, what devices were used for pressure relief, and the nutritional status of the patient. The Braden Scale was the most widely used tool by twenty-nine of the facilities that participated in this survey. The other fourteen facilities used a tool adopted by their facility, the Norton Plus Scale, the Minimum Data Set (MDS) reporting, and the clinical judgment of the staff.  Eighty-six percent performed their skin assessments weekly, one facility performed the low risk patients monthly, and two facilities performed daily skin assessments. Ninety-one percent of the facilities used pressure relief mattresses and turning schedules for the low at-risk patients and ninety-three percent used this strategy for patients at a high risk of developing pressure ulcers. The facilities with the high-rick patients utilized a nutritional supplement and dietary referral for proper nutrition. The strategy used in 96% of the facilities with low-risk patients initiated a toileting schedule, barrier creams, and indwelling catheters to prevent ulcers from forming. The high-risk facilities employed a Registered Nurse as their wound care professional. Nursing leaders of each of these facilities used a facility-based tool to educate their staff on the prevention and treatment of pressure ulcers (Rapp et al., 2010).

       Pressure ulcers are not only a problem in the United States but also considered a global problem for all patients in long-term care facilities. Four long-term care facilities from the Brazilian state of Minas Gerias conducted a study to examine the occurrence of pressure ulcers of elderly people living in long-term care facilities. A total of ninety-four people aged 60 or older were included in this study, were female, and of the Caucasian decent. Their ages ranged from 60 to 103 years of age, 58.4% had urinary incontinence, 57.4% respiratory complications, 52.1% were prescribed psychotropic medications, and 38.3% were prescribed antihypertensive medications.  The facilities used the Braden scale and a complete skin assessment every two days for three months. If a Stage II pressure ulcer was discovered, the stage, size and location were documented. Every patient that scored an 18 or less was included in this study unless a pressure ulcer was detected, death occurred, they were transferred to another facility, or discharged from the facility. The results of this study suggested that 37 of the participants developed a pressure ulcer within the first month of admission, with the rate of 20.2% due to poor mobility (Souza & Snatos, 2010).

A National Pressure Ulcer Long-Term Care Study (2004) was performed in 95 long-term care facilities in the United States between February 1, 1996, and October 31, 1997 that included 1,524 residents. The average age of the residents was 19, the average inpatient stay of the residents was 14 days, and  recognized as being at risk for the development of pressure ulcers. The Braden Scale was used for this study and the average score of 17 or less in the categories listed on the scale, suggested that the participants at risk for the development of pressure ulcers.  This study utilized the Braden Scale to assist with the residentís plan of care and each resident was assessed upon admission, within 48 hours after admission, and then once a week for the remainder of the patientís stay. The facilities in this study supplied information of their staffing patterns, if an outside wound consultant was utilized, and if they used a nutritional supplement for their medication administrations. This study suggested that residents newly admitted to the facilities, were not as likely to develop pressure ulcers as existing residents. Weight loss due to oral problems put the residents at a higher risk of developing a pressure ulcer and improper wound healing associated with improper nutrition. This study also suggested that residents that developed a Stage I to Stage IV pressure ulcer had a history of pressure ulcers; their illness was more severe than other residents, developed significant weight loss, had a history of oral problems, and had an indwelling catheter for incontinence issues (Horn et al., 2004). 

       According to the Illinois Council of Long Term Care, (2010), the primary risk factor for the development of pressure ulcers is impaired or decreased mobility. Patients that are unable to turn themselves need a turn schedule every two hours in place at the time of admission to prevent development of pressure ulcers. Secondary risks include advanced patient age, reduced sensory perception, hip fractures, incontinent of bowel and/or bladder, poor nutrition and hydration, impaired cognitive abilities, renal insufficiency, diabetes, fever, and a lower than 98.6 body temperature. Other factors that increase the risk of pressure ulcers include friction and shear, having reduced nutrition and hydration, and rooms with less than 40% humidity (which dries the skin). Minimizing friction and shear when turning, positioning, and transferring patients, and applying a protective barrier cream after each incontinent episode will decrease the chance of developing a pressure ulcer (Illinois Council on Long Term Care, 2010a).

       Delmore et al., (2011) conducted a survey to revise The New York University Medical Centerís current pressure ulcer policy. The new policy adheres more closely to the new Center for Medicare and Medicaid Services Policy on the reimbursement for hospital-acquired pressure ulcers. Delmore et al., (2011) outlines the steps taken to revise their current policy to prevent pressure ulcers.

       The New York University Medical Center has two campuses and they are Magnet facilities. The main campus hospital contains 879 beds, which include hospital patients and rehabilitation patients. The other campus treats orthopedic and neurologic patients. They devised an eight spoke system that included the patient as the main focus and the outlying areas of using support mattresses, patient family education, clinician training, protocols and procedures, assessment, skin care, nutrition, hydration, and the prevention of extrinsic factors. The survey was initiated in the preoperative services department and suggested that most pressure ulcers develop within 48-72 hours after surgery. Staff education in this department was reviewed, and suggested that the staff were under-educated in the prevention of pressure ulcers. A program was developed in this area to identify patients who were at risk of developing pressure ulcers, by placing a wristband on those patients who would remain in the same position for at least four hours during their procedure. This wrist-band remained in place upon discharge from the operating room to the floor. This system helped the floor to identify those patients at a higher risk for developing pressure ulcers. The bed support mattresses that were used on the floor were evaluated and surfaces that were more than ten years old were replaced in order for the prevention process to be successful. The findings of this survey suggested that by utilizing this process, their pressure ulcer rate decreased from 7.3% to 1.3% over a three- year period (Delmore et al., 2011).

      The University of Pennsylvania Health System included four separate hospitals, which united to form the Penn Medicine Pressure Ulcer Collaborative. This collaborative consisted of wound care, quality control, and risk management personnel. The estimated cost of treating a pressure ulcer can range from $2,000 to $70,000 depending on the severity of the wound (Carson et al., 2012). The use of evidenced-based practice, understanding how the problem arose, the extent of the success of the program, and utilizing available clinical resources is the initial phase of a high-quality pressure ulcer prevention program. The evidence-based approach included improving the documentation of pressure ulcers upon and during admission, decreasing the amount of layers of linen used on the patientís bed, creating an order set for the prevention and management of pressure ulcers, and using photography to document the healing process of the pressure ulcers. The collaborative used the National Database for Nursing Quality Indicators as the way to measure the success of their program. Each institution employs one wound care nurse to observe the treatment and prevention of pressure ulcers. The collaborative also developed a guide that is given to patients and families upon admission to educate them on the prevention of pressure ulcers. The results of developing the collaborative in the four entities reduced the incidence of pressure ulcers from 85% to 37%. This study suggested that working together is the best prevention of pressure ulcers of hospitalized patients (Carson et al., 2012).

      Horn et al., (2010) studied seven states that encompassed eleven long-term care facilities in Pennsylvania, Wisconsin, South Dakota, New York, Texas, and Michigan, with five long-term care facilities located in Ohio. These facilities agreed to participate in a real time program that would facilitate the use of a uniform Certified Nursing Aide documentation checklist to recognize the residents that were at a high risk of developing pressure ulcers. The documentation would be completed on a weekly basis and the document would be given to the project facilitators. This program consisted of five areas for the quality improvement of pressure ulcers. These five areas addressed in the project included; incorporating specific questions to be answered in the Certified Nurses Aideís documentation, generating information to help the nurse assistants in determining which residents are at risk for the development of pressure ulcers. The staff was provided on-going education related to use of the documentation, incorporating the quality improvement tools on a day-to-day flow-sheet for easier documentation, and shared this documentation between all facilities involved in the survey. The development process area included instituting a multi-disciplinary team that consisted of the Director of Nursing, wound care nurse, or the Minimum Data Set (MDS)  nurse, certified nurse assistants, and staff nurses. Biweekly teleconferences were held with the project facilitator to evaluate the progression of the new tool. Elements included in the teleconferences were the meal consumption of the residents, any weight changes from week to week, and if the resident was incontinent of either bowel or bladder and wore disposable underwear. A weekly summary of the certified nurse assistantís documentation was reviewed and was expected to be in the range of 75% to 100% for being complete.  The results of this survey suggested that by integrating standardized documentation across the facilities in this study, it can improve the quality report to help identify those residents who are at a high risk of developing pressure ulcers and to take the initiative to help prevent pressure ulcers (Horn et al., 2010).

       Lyman, (2009) conducted a quality improvement study at the Loretto Health and Rehabilitaion Center in Syracuse New York to prevent heel pressure ulcers in their long term care facilities of 550 patients. This facility implemented a pressure relieving heel protector for those residents who received a score of less than 18 on the Braden Scale, had co- morbidities of diabetes, peripheral vascular disease, stroke, weakness, hip fractures, total knee replacements, and those that were receiving vasopressor medications. The nurses also conducted frequent skin assessments on those patients who were at a higher risk for the development of heel pressure ulcers. Prior to this study, pressure ulcers at the facility ranged from 3-13 per month and after implementation, the occurrence of pressure ulcers were reduced to 0-15 per month. The results of this study suggested  using risk assessments on those patients at a high risk for the development of pressure ulcers, an appropriate skin assessment upon  admission and during the patientís stay, and applying heel protectors to those patients at risk, saved the facility $1,048,400 per year in the treatment of pressure ulcers (Lyman, 2009).

      Proper nutrition has also been reported to play an important role in the prevention and treatment of pressure ulcers. According to Dorner, Posthauer, and Thomas (2009), there are one to three million people every year in the United States that may be at risk or develop pressure ulcers. Sufficient calorie intake of proteins, carbohydrates, and vitamins are necessary for sustaining proper tissue integrity and perfusion. Patients with inadequacies in these areas, along with age, mobility, and a history of pressure ulcers, increase their risk of developing a new pressure ulcer. This study suggested that unintentional weight loss increased the patientís risk of pressure ulcers. These patients are weighed daily and proper documentation of their weight is recorded. In this case, a registered dietician should be involved in the daily management of the patientís diet and intake. This study also suggested that that proper nutrition may improve the patientís quality of life and healing (Dorner et al.).

      According to Lahmann, Tannen, Dassen, and Kottner (2011), the most prevalent items associated with the development of pressure ulcers included friction and shear. A six point Braden scale was used in this study. The items that characterized the risk factors were sensory perception, moisture, activity, mobility, nutrition, friction and shear. This study consisted of 19, 381 residents in 234 facilities throughout Germany from 2004 to 2009. The sample consisted of 79.8% female, 20.2% male and the average age of the participants was 83.8. The results suggested that friction and shear should have more emphasis on the Braden scale in order to reduce the number of pressure ulcers in a long term care facility (Lahmann et al., 2011).

Suggested Treatment Regimes

      To treat pressure ulcers, the stage of the ulcer should be determined. To treat a Stage I pressure ulcer, the nurse should eliminate all sources of pressure, friction, and shear potential. A dressing is usually not needed for this stage, but a barrier cream may be applied to help prevent any further damage. Stage II pressure ulcers may be treated by using a mattress overlay or obtaining an order from a physician for their recommendations. The ulcer should be cleansed with normal saline, patted dry and a hydrogel dressing applied if minimal exudate is present. If moderate exudates is present, the same steps should be followed and the dressing changed every three to four days or if soiled or leakage is present. The first step in treating stage III or IV ulcers is to try and eliminate all sources of pressures, friction or shear. Wounds of this stage with minimal exudates may be cleansed with normal saline, a dressing applied, and changed if soiled or if leakage is present (Illinois Council on Long Term Care, 2010b).

      According to House, Giles, and Whitcomb (2011), if a patient is admitted with a Braden scale of less than fourteen, is admitted with a pressure ulcer, and is greater than 300 pounds, a wound care consult and a nutritional consult should be initiated. If patients score more than fourteen, but less than eighteen, they should be placed on a pressure relief bed, turned every two hours, have a pressure relieving device in their chair, and avoid being turned directly onto their trocanters. If the patient is incontinent, linens should be changed frequently, and skin barriers should be applied. When repositioning the patient, avoid friction and shear, do not massage any areas, use heel protectors while in bed, and elevate the head of the bed to a 30 degree angle. The Naval Medical Center at Portsmouth, Virginia implemented a pressure ulcer treatment plan in 2009. This treatment plan covered pressure ulcer from Stage I to Stage IV. Their treatment plan for Stage I pressure ulcers were to protect the patientís skin from further damage, apply barrier cream frequently, and to initiate a two hour turning schedule. Stage II ulcers were covered by a hydrocolloid dressing, involved a two hour turning schedule, and the skin was assessed each shift for further breakdown. Stage II pressure ulcers required a wound care consult and were followed as ordered. Stage IIII ulcers required a physician consult, a special mattress for the bed, and a two hour turning schedule (House, et al., 2011).

       Abraham, (2010) conducted  literature reviews from four studies, from the Medline and OVID databases to determine if Xenaderm was effective in the treatment of pressure ulcers and wound care management. The results of this study suggested that Xenederm encourages healing, increases blood flow to the affected tissues, develops epithelialization of tissue, and acts as a protective barrier to the skin. Xenederm can also reduce the pain caused by pressure ulcers, does not need a secondary dressing applied, and will save the institution money by reducing the amount of supplies needed to care for pressure ulcers. The average cost of using Xenederm is $1.90 per day, as compared to other types of treatment which may cost up to $3.62 per day.  The Centers for Medicare and Medicaid Services has considered Xenederm a non-reimbursable cost because of the lack of evidence supplied to treat pressure ulcers (Abraham, 2010).

      Moore, Cowman, and Conroy (2011) conducted a study in urban and rural Ireland in long term care facilities to suggest that using a 30 degree tilt in the position of patients will prevent pressure ulcers. The Braden scale was the tool used to determine if the patients were at risk for the development of pressure ulcers. The participants were over the age of 65, were determined to be at risk of developing a pressure ulcer, did not have a current pressure ulcer, and were medically stable. An experimental group and a control group were utilized. The control group contained 114 patients and the experimental group 99 patients. Fifty-three percent of the patients were between the age of 80-90 and 13% were ages 90-100, with seventy-nine percent of the participants being women. The experimental group was repositioned using this method every three hours during the night. The control group was repositioned with this method every six hours during the night. The results of this study suggested that three patients in the experimental group developed a pressure ulcer as compared to thirteen patients in the control group. The use of the 30 degree tilt method, along with a three hour repositioning schedule will help to reduce the incidence of patients developing pressure ulcers (Moore, et al, 2011).

 Summary

      A summary of the literature review suggested the Braden Scale is the most widely used scale in determining which patients are at risk of developing a pressure ulcer. The literature also suggested that proper skin care, nutrition, and minimizing friction and shear, placing a mattress overlay on at risk patients, and a prompt turning schedule should be implemented to prevent pressure ulcers from developing. All patient care staff needs to be educated on these areas to decrease the patientís risk.

 Methodology

      The study utilized a quantitative method, descriptive design, reviewing an existing policy for pressure ulcers (Appendix A), noting any changes that need to be made, and finalizing a new policy from evidence retrieved from the literature review.  The descriptive method was chosen for this proposed study to help gain insight on the proper prevention and treatment of pressure ulcers and to identify the problems with the current policy and treatment.

Setting

     This descriptive study took place at the Rehab and Skilled Nursing units in a forty- bed facility in rural Midwestern Illinois. The ages of the patients on the units range from 70 to 93 and included approximately 75% women and 25% men. The patients are admitted with hip and pelvic fractures, strokes, deconditioning, and failure to thrive diagnoses. While the patients are described for understanding, they will not be involved in the study as participants. In fact, there is not a sample involved in this proposed project. Rather it is an extensive review of the literature related to the appropriate nursing care of pressure ulcers guiding the process for the development of a policy reflecting current evidence based nursing practice.

Protection of Human Subjects

       All human subjects were protected during this study, no patients were interviewed, and no experimental treatments were used. There is no risk involved in the new policy to staff members but patients may experience temporary pain when dressings are changed involving Stage III and Stage IV pressure ulcers. No patient records were viewed, only the policy related to pressure ulcer care. Institutional Review Board approval was secured from McKendree University and the facility involved.

Procedure

       The literature review suggested that most institutions employ the Braden scale to determine which patients are at risk for developing pressure ulcers. Not only is the Braden scale used in the United States, as the literature suggests, it is also used in other countries. Most institutions use Santyl, which is an enzymatic debridement agent, as a first line of treatment for the healing of current Stage III and Stage IV pressure ulcers. The new policy will be introduced and discussed in a weekly meeting with all patient care staff and copies will be distributed. A representative from a wound care company will also attend the meeting to discuss the benefits of proper wound care to aid in the healing process. The healing or declining progress of the pressure ulcers will be documented in the patientís chart daily and a weekly photograph placed in the patientís chart for physician review to test the reliability of the new policy and the determine the consistency of treatment. The utilization of proper wound care, positioning, nutrition, and minimizing friction and shear will aid in the prevention of patients acquiring new pressure ulcers. There is no risk involved in the new policy to staff members, but patients may experience temporary pain when dressings are changed involving Stage III and Stage IV pressure ulcers. Administering pain medication one half- hour before the dressing change may decrease the patientís discomfort.

 Strengths

       The strengths include a review of the literature using current evidence on which to base a new policy. The new policy ensures continuity of care so patients will have more positive outcomes to the healing of current or newly acquired pressure ulcers. All staff will follow the new policy, which provides closer monitoring of the healing process and documentation of current and newly acquired pressure ulcers will be uniform. This is relevant to reducing costs to the facility related to the healing process.

Limitations

      The anticipated limitations of this study include the policy being written for one facility in rural Midwestern Illinois. The patients in this study had limitations of sensory perception, incontinence, mobility, nutrition, and possible friction and shear.

Summary

      This study includes a newly revised policy to reduce the number of new pressure ulcers, using evidence- based treatments gleaned from the current literature. The current evidence used for the revised policy indicates faster healing and reduced costs to the facility related to treating pressure ulcers. The proper treatment of existing pressure ulcers aids in the healing process and helps improve the patientís outcome and quality of life.

 

Discussion

      A current literature review for the best practice for prevention and treatment of pressure ulcers and a review of the patientís charts were conducted. After reviewing the charts and the current literature, the new policy was formatted to include the results for the best practice in the prevention and treatment of pressure ulcers. The policy was written with a positive content, such as who will be affected by the prevention and treatment, and the staff responsible for the prevention and treatment of pressure ulcers. The new policy contained simple language to ensure it was easily understandable. The Nurse Practice Team and upper management evaluated the revised policy and made suggestions, corrections, or additions where necessary. The revised policy was issued to staff at a weekly unit meeting with time given for questions to make certain it was understood. After review, all staff acknowledged the new prevention and treatment of pressure ulcers.

           Strengths

       The strengths of re-writing a new policy are numerous. First, is review by numerous managers before implementation, ensuring that best practice is properly followed. The prevention of pressure ulcers saves the patient from costly and painful treatments, co-morbidity such as infections, lengthy hospital stays, and will save the institution money by preventing new pressure ulcers and the treatment of existing pressure ulcers. Additionally, healing existing pressure ulcers in less time without discomfort achieves the best possible outcome.

           Limitations

     The limitations of instituting a new policy and procedure include only one person conducted a literature review to ensure that best practice is followed. Another limitation includes that the policy was written for a specific unit of the hospital and will only be used in that capacity. Further research should be completed by reviewing the most current literature on a regular basis to check for any new evidence based practice changes. Other limitations of the process include the time it takes to review current literature for best practice, writing the revised policy, and the time it takes to institute the new policy.

         Conclusion

      The completed new policy on the treatment and prevention of pressure ulcers indicated that current pressure ulcers were healed faster, reducing the amount of pain and discomfort to the patient, decreased co-morbidities such as infection, improved the patientís outcome and hospital stay, and reduced the cost to the facility relating to the treatment and prevention of pressure ulcers.   

    

 References

Braden, B., & Bergstrom, N. (1998). Braden scale for predicting pressure sore risk. Retrieved from www.Bradenscale.com

Carson, D., Emmons, K., Falone, W., & Preston, A. M. (2012). Development of pressure ulcer program across a university health system. Journal of Nursing Care Quality, 27(1), 20-27.

Delmore, B., Lebovits, S., Baldock, P., Suggs, B., & Ayello, E. A. (2011). Pressure ulcer prevention program: a journey. Journal of Wound, Ostomy, and Continence Nurses Society, 505-513.

Dorner, B., Posthauer, M. E., & Thomas, D. (2009). The role of nutrition in pressure ulcer prevention and treatment: national pressure ulcer advisory panel white paper. Advances in Skin and Wound Care, 22(5), 212-221.

Horn, S. D., Bender, S. A., Ferguson, M. L., Smout, R. J., Bergstrom, N., Taler, G.,...Coble Voss, A. (2004, March 24). The national pressure ulcer long-term care study: pressure ulcer development in long-term care residents. Journal of American Geriatric Society, 52(3), 1-14.

Horn, S. D., Sharkey, S. S., Hudak, S., Gassaway, J., James, R., & Spector, W. (2010). Pressure ulcer prevention program in long-term care facilities: a pilot study implementing standardized nurse aide documentation and feedback reports. Advances in Skin and Wound Care, 23, 120-131.

House, S., Giles, T., & Whitcomb, J. (2011). Benchmarking to the international pressure ulcer prevalence survey. Journal of Wound Ostomy Continence Nurse, 38(3), 254-259.

Illinois Council on Long Term Care (2010a). Pressure Ulcer Prevention, 1-7. http://www.roadtoexcellence.org.

Illinois Council on Long Term Care (2010b). Pressure ulcer treatment,1-2.

            http://www.roadtoexcellence.org.

Kwong, E. W., Pang, S. M., Aboo, G. H., & Law, S. S. (2009). Pressure ulcer development in older residents in nursing homes: influencing factors. Journal of Advanced Nursing, 65(12), 2608-2620. doi.org/doi:10.1111/j1365-2648.2009.05117

Lahmann, N. A., Tannen, A., Dassen, T., & Kottner, J. (2011). Friction and shear highly associated with pressure ulcers of residents in long-term care - Classification Tree Analysis (CHAID) of Braden items. Journal of Evaluation in Clinical Practice, 17, 168-173. doi.10.1111/j.1365-2753.2010.01417

Lyman, V. (2009). Successful heel pressure ulcer prevention program in a long-term care setting. Journal of Wound, Ostomy, and Continence Nurses Society, 36(6), 616-621.

Mathais Abraham, L. (2010). Xenederm: an essential wound care therapy. Advances in Skin and Wound Care, 73-76.

Moore, Z., Cowman, S., & Conroy, R. M. (2011). A radomized controlled clinical trial of repositioning, using the 30 degree tilt, for the prevention of pressure ulcers. Journal of Clinical Nursing, 20, 2633-2644. doi.10.1111/j.1365-2702.2011.0373

 Rapp, M. P., Nelson, F., Slomka, J., Persson, D., Cron, S. G., & Bergstrom, N. (2010). Practices and outcomes: pressure ulcer management in nursing facilities. Nursing Administration Quarterly, 34(2), 1-11

Sebba Tosta de Souza, D. M., & Conceicao de Gouveia Snatos, V. L. (2010). Incidence of pressure ulcers in the instiutionalized eldery. Journal of Wound Ostomy Continence Nursing, 37(3), 272-276.

Tescher, A. T., Branda, M. E., Byrne, T. O., & Naessens, J. M. (2012). All at risk patients are not created equal-Analysis of braden pressure ulcer risk scores to identify specific risks. Journal of Wound, Ostomy, Continence Nurse, 39(3), 282-291.

Zulkowski, K., & Gray-Leach, K. (2009). Staging pressure ulcers: whatís the buzz in wound care? American Journal of Nursing, 109(1), 27-30.

 

  

Appendix A

Policy:

To assess the pressure ulcer(s) initially for location, stage, size, sinus tracts, undermining, tunneling, exudates, necrotic tissue and the presence or absence of granulation tissue and epithelialization.

Procedure:

Pressure ulcer(s) is defined as any lesion caused by unrelieved pressure resulting in damage of underlying tissue:

     Stage I

         Non-blanchable erythema of intact skin, heralding lesion of skin ulceration. In individuals     

         darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be

         indicators.

     Stage II

         Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and

         Presents clinically as an abrasion, blister, or shallow crater.

     Stage III

         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.

     Stage IV

          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 associated with Stage IV ulcers.

Assess the pressure ulcer and document:

         Location

         Size

         Sinus tract

         Undermining

         Tunneling

         Exudates

         Necrotic Tissue

         Presence or Absence of Granulation Tissue

        

Assess all residents for pain related to the pressure ulcer or its treatment

 

Positioning techniques and support surfaces for residents in bed are important factors in management of pressure ulcers.

         Avoid positioning resident on pressure ulcer

         Reposition resident at a 30 degree angle

        Avoid using donut-type devices

        Establish repositioning schedule

 

Wound cleansing Ė wound healing is optimized and the potential for infection is decreased when all necrotic tissue, exudates, and metabolic wastes are removed from the wound. Do not use antiseptic to clean wound. Use Normal Saline for wound cleansing.

 

 

 

Appendix B

Proposed New Policy

Pressure Ulcer Prevention and Treatment

 

Policy:

 

It is the policy of this facility that residents shall receive appropriate assessment and management for pressure ulcer prevention and treatment.

Procedure:

(1). Residents shall be assessed for skin integrity upon admission and appropriate measures for pressure ulcer prevention and treatment will be implemented within the residentís care plan.

(2). A Braden score is to be completed by the charge nurse at time of admission.

(3). A photograph will be taken upon admission

(4.). A dietary consult for nutritional support will be instituted to assure adequate dietary intake

        of protein to promote healing

(5). A Stage II pressure ulcer or greater; an additional vitamin supplement should be instituted

       Examples of additional Vitamin C (500mg twice daily), Zinc Sulfate (220mg daily), and

       Multivitamins

(6). With a Physicianís order, additional labs may be drawn

        Examples of labs may include: Albumin and Protein levels

       Patients who are a low risk for the development of pressure ulcers, (a score of 15 -16)

       on the Braden scale:

         Staff may institute interventions to decrease moisture and friction and shearing

         Increase the patientís toileting schedule

         Protect heels

         Remind patient to turn and reposition while in a chair and while in bed.

         Staff may apply lantiseptic as a preventative measure

      Patients who are at a moderate risk for the development of pressure ulcers, (a score of

      13-14) on the Braden scale:

          Staff may institute interventions of a 2 hour turning schedule

          Apply air reduction support surface while in bed or in a chair.

          Apply heel protectors or float heels on a pillow while in bed.

          Toilet the patient every 2 hours, checking for incontinence of bowel or bladder

       Patients who are at a high risk for the development of pressure ulcer, (a score of 12

       or less) on the Braden scale:

            Staff may place a pressure reduction support surface to the bed and in the chair

            A 1- hour turning schedule should be instituted and check patient for incontinence of

            bowel or bladder

            The heels should be floated on pillows or heel protectors applied while in bed

            Encourage extra fluids

            Increase the patientís protein intake with every meal and as a supplement between

            meals

Suggested treatment for Skin Tears with a viable flap:

          The skin tear should be cleansed with Normal Saline or wound cleanser

          Apply steri-strips

          Apply a tegaderm dressing

          Change the dressing and cleanse the wound every 5 days and as needed if soiled or if

          drainage present

 

Suggested treatment for Skin Tears without a viable flap, surrounding tissue not fragile:

           The skin tear should be cleansed with Normal Saline or wound cleanser

           Apply triple antibiotic ointment

           Apply a telfa and tegaderm dressing

          Change the dressing and cleanse the wound every 5 days and as needed if soiled or if

          drainage is present

Suggested treatment for Skin Tears without a viable flap and extremely fragile skin:

         The skin tear should be cleansed with Normal Saline or wound cleanser

        Apply triple antibiotic ointment

        Apply a telfa and/or kling and change and cleanse the wound daily

Stage I

        Non-blanchable erythema of intact skin, the heralding lesion of skin ulceration. In

        individuals with darker skin, discoloration of the skin, warmth, edema, induration, or

        hardness may also be indicators.

 Suggested treatment for Stage I Pressure Ulcers

        Initiate Braden scale upon admission and then weekly for entire admission.

        Assess patient upon admission for any areas of redness, warmth or edema.

        Take an admission photograph to be placed in the chart for physician review.

        Institute a 2- hour turning schedule

       Apply lantiseptic or barrier cream to affected areas.

       Apply heel protectors or float the heels on pillows while in bed.

 

 

 Stage II

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

Suggested treatment for a shallow pressure ulcer with a red wound bed with none or minimal amount of exudate:

        Cleanse wound with Normal Saline or Wound Cleanser

        Apply skin protectant around wound

        Apply a pink Polymem

        Cover with gauze and secure with tape.

        Change dressing and cleanse wound daily and as needed if soiled or if drainage is present

  Suggested treatment for a shallow pressure ulcer with a red wound bed with a moderate

   to large amount of exudate:

         Cleanse the wound with Normal Saline or Wound Cleanser

         Apply a protective barrier wipe to protect the surrounding skin

         Apply adaptic and silver cell to the wound bed

         Cover with gauze and/or ABD pad and tape in place

         Change dressing daily or as needed if soiled or if drainage is present

  Suggested treatment for a deep pressure ulcer with a red wound bed with none to minimal amount of exudate:

         Cleanse the wound with Normal Saline or wound cleanser

         Apply a protective barrier wipe to protect the surrounding skin

         Apply adaptic and silver cell to wound bed

         Cover with gauze and tape in place

         Change dressing daily or as needed if soiled or if drainage is present

Suggested treatment of a deep pressure ulcer with a red wound bed with moderate to large amount of exudate:

           Cleanse the wound with Normal Saline or wound cleanser

           Apply a protective barrier wipe to protect the surrounding skin

           Line the wound bed with Non-Adherent Silver Cell

           Pack the wound with dry gauze

           Cover with gauze and/or ABD pad and tape in place

           Change the dressing daily or as needed if soiled or if drainage is present

 Stage III

        Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may

        extend down to, but not through the underlying fascia. The ulcer presents clinically as a

        deep crater with or without undermining of adjacent tissue.

Suggested treatment of a shallow wound with a yellow wound bed with a minimal amount of exudate:

        Cleanse wound with Normal Saline or Wound Cleanser

        Apply skin protectant around wound

        Apply Santyl to wound bed

        Cover wound with gauze and secure with tape

        Change dressing daily or as needed if soiled or if drainage is present

 

 

Suggested treatment of a shallow wound with a yellow wound bed with moderate to large amount of exudate:

              Cleanse with Normal Saline or Wound Cleanser

              Apply skin protectant around wound

              Apply Santyl or Non-Adherent Silver Cell to wound bed

              Cover with gauze and secure in place with tape

              Change dressing daily or as needed if soiled or if drainage is present

Suggested treatment of a deep wound with a yellow wound bed with none to minimal amount of exudate:  

               Cleanse with Normal Saline or wound cleanser

               Apply skin protectant around wound

               Apply Santyl to wound bed

               Apply Adaptic

               Cover with gauze and secure in place with tape

               Change dressing daily or as needed if soiled or if drainage is present

Suggested treatment of a deep wound with a yellow wound bed with moderate to large amount of exudate:

                Cleanse with Normal Saline or wound cleanser

                 Apply skin protectant around wound

                 Apply Santyl and Non-Adherent Silver Cell to wound bed

                 Pack with dry gauze

                 Cover with ABD pad and secure with tape

                 Change dressing daily or as needed if soiled or if drainage is present

Stage IV and Non-Stagable

       Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle

       bone, or supporting structures (e.g. tendons, or joint capsule). Undermining and sinus tracts

       also may be associated with Stage IV ulcers.

Suggested treatment for a wound below the knee with a black wound bed and no drainage or signs of infection:

                Leave eschar intact

               Apply heel protectors or float heels to minimize heel pressure

 Suggested treatment for a wound below the knee with a black wound bed with drainage:  

               Cleanse wound with Normal Saline or wound cleanser

               Apply skin protectant around wound

               Apply Santyl to wound bed

               Cover wound with a dry gauze and wrap with kling

               Change dressing daily or as needed if soiled or if drainage is present

Suggested treatment for a wound above the knee with a black wound bed with none to minimal amount of exudate:

               Cleanse wound with Normal Saline or wound cleanser

               Apply skin protectant around wound

               Apply Santyl to wound bed

               Cover wound with gauze and/or ABD and secure with tape

                Change dressing daily or as needed if soiled or if drainage is present

 

Suggested treatment for a wound above the knee with a black wound bed with moderate to large amount of exudate:

              Cleanse wound with Normal Saline or wound cleanser

              Apply skin protectant around wound

              Apply Santyl to wound bed

              Cover wound with gauze and/or ABD pad and secure in place with tape

              Change dressing daily or as needed if soiled or if drainage is present