Innovations To Prevent and Treat Pressure Ulcers
"V 'Y V ' v V "V V 'Y V V V ' ~ " V ' V 'Y V ' T Y 'Y ~
The '80s brought refinements in assessment, plus a wave of new products and techniques. Is your practice up to date? BARBARA J. BRADEN RUTH BRYANT ' n reviewing how the art and science of preventing and treat. ing pressure ulcers has changed over the past 10 years, one is struck by the dichotomy: Little has changed and yet much is radically different. Practice has.been slow to catch up with science in some areas and has raced ahead in others. Changes in our knowledge of factors that contribute to pressure ulcers have heightened our ability to identify those at risk for developing them. And our refined knowledge guides our strategies for preventing ulcers as well as hastening wound healing when a pressure ulcer develops.
l
Who Is At Risk? Nurses have long appreciated the need for a reliable way to assess patient risk for pressure ulcer development: The first tool, the Norton Scale, developed by Doreen Norton, a British nurse, has served as a model for all subsequent assessment tools, including the Gosnell Scale in 1973 and the Braden Scale in 1987 (1-3). While the Norton tool has been Barbara J. Braden, RN, PhD, is an associate professor of gerontological nursing at Crcighton University School of Nursing, Omajla, NE. She has been involved in research and development of the Braden scale for predicting pressure ulcers and was project director of Creighton University Teaching Nursing Home Project. Ruth Bryant, R N, MSN, is director of the Enterostomal Therapy Nursing Education Program at Abbott Northwestern Hospital, Minneapolis, MN. She has been a practicing. enterostomal therapy nurse for 10 years and staffs a busy clinic.
182 Gerialrie Nursing July/August 1990
widely used in England, risk assess- tice has been to evaluate the patient ment has not disseminated in the only on admission. While this allows practice arena here. Until recent the nurse to identify those patients years, we seemed to expect nurses to who are at highest risk, it's not possiidentify those at risk from a gestalt of ble to learn enough during the admisroutine assessments. Outside forces sion assessment to identify lesser desuch as reimbursement, the nurse grees of risk accurately. Risk assessment should be repeatshortage, the expense of therapeutic beds, a n d the aging of the patient ed 24 to 48 hours following admispopulation are driving the change to sion and whenever the patient's con• dition changes thereafter. It is wise to assess more precisely. One force with which nurses in- specify in the nursing protocols an increasingly must reckon is reimburse- terval for reassessment that reflects ment under the current prospective the rapidity with which patient conpayment system for Medicare pa- ditions usually change in the given tients. Reimbursement under the setting. For example, one might set DRG is limited when a patient devel- the interval at daily in the intensive ops a pressure ulcer during hospitali- care unit, every 48 hours on medicalzation. Such an incident will trigger a surgical floors, weekly in skilled local Peer Review Organization re- nursing facilities, and monthly in inview of nursing services provided termediate care facilities. A number of factors that are not so during the patient's stay(4). The Joint Commission of Accredi- easily included in a risk score may tation of Hospitals Organization contribute to pressure ulcer developconsiders hospital-acquired pressure ment. These include low blood presulcers an indicator of poor care and sure and other hemodynamic expects evidence that a program to changes; elevated body temporature; prevent such occurrences is in place emotional stress; smokifig; and skin and working. Risk assessment is the temperature. Systolic blood pressures below 100 cornerstone of such a program. To assure care that is cost efficient, mm Hg and diastolic pressures below an assessment tool should be fairly 60 have been associated with existing accurate in predicting who will and pressure ulcers for a number of will not develop a pressure ulcer, and years(2). This level ofhypotension is different nurses should reliably ob- not unusual among the institutionaltain the same rating when assessing a ized elderly, and low diastolic prespatient. The Braden scale has proved sure has been found to be highly prevery accurate in identifying those dictive of pressure sore develop-. who will develop a pressure ulcer; it ment(8). It is especially important to also overpredicts less than other reduce surface pressure in elders with tools(5-7). The Braden scale takes sustained low blood pressures. Increased blood viscosity and high less than a minute to complete and hematocrit have also been associated can be used reliably by RNs. The prevailing assessment prac- with tissue damage(9). While dehy-
USING THE RIGHT TERM
dration has often been mentioned as predisposing a patient to pressure ulcer development, improving hydration rarely gets enough attention in preventive protocols. The association between elevated body temperature and pressure ulcer formation is not known, though it seems likely that the catabolic state accompanying infection plays some part(2,8). In elderly subjects, even a mild elevation may raise the risk for pressure ulcer development. Another recent developmenfis the association of psychosocial issues with pressure ulcer formation. Pressure ulcers have been linked to patients' low motivation and emotional energy to care for themselves and to the physiological changes that take place during emotional stress(10). There is also evidence of a link between the stress of relocation to a nursing home and superficial pressure ulcers occurring during the first month following admission(l 1). This and other findings regarding the timing of most pressure ulcer development within two weeks of ad• mission underscore the importance of intensive prevention in the early days following admission. It may also be appropriate to reformulate nursing home admission procedures to lower the stress that arises out of uncertainty and to promote a sense of l~rsonal control. Evidence that smoking may contribute to pressure ulcer formation is beginning to accumulate. Lamid and El Ghatit, in a study of spinal cord injured patients, found a significant positive correlation between cigarette smoking and the presence of pressure ulcers(l 2). These investigators also reported that the incidence and extent of existing ulcers were greatest in those patients with high pack-year histories.
Abandoning Prevention Myths Just as our ideas concerning risk factors and risk assessment have changed over the past ten years, so have our ideas concerning appropriate preventive measures(13,14). The oldest interventions in a nurse's armamentarium came under fire in the '80s: The standard turning schedule ofevery two hours has given way
Granule. pra~(~nce of smltll, bl(X~d vessels and cQnnect~e Us~u_e;wound, al~ pears r~d. grainy~.andm-oist
Cellulitis: ~yergrowlh of bavaria in wound creating Iocal~lgns,suchas eryo thema, drainage, and warmth Denude: loss of superficial tissue, epidermis Erythema: redness of skin surface produced by vasodHation Eschar:. Hard, black, crusted nonviable tissue
Excoriation: linear scratch marks Necrotic avascular, dead Nonvlablez (lead Slough: loose, stringy necrotio tissue Stage 1: erythema Stage 2: blister or tissue loss limited to epidermis or dermis Stage 3: tissue loss extending into subcutaneous tissue Stage 4: tissue loss extending into muscle. bone. or tendon Wound base: bed of wound Modified from Standards of Care, Dermal Wounds: Pressure Sores. Irvlne,CA, International Assooiation for Enterostomal Therapy, 1987.
to an individualized turning schedule planned ai'ound patient meals and care activities. And more frequent turning to a variety of positions, not just side-back-side, is now being encouraged. The recommended alternative to the lateral position is the 30-degree oblique position in which one can almost totally avoid pressure over bony prominences. A turn of only 30 degrees to the side also has the advantage that it can usually be done by one caregiver using a couple of pillows. The rule of only 30 degrees should also be applied to elevating the head of the bed. A slight elevation of the head of the bed may shift some pressure points, but .more elevation will cause increased pressure, friction, and shear. The practice of massaging reddened areas over bony prominences is no longer considered appropriate
skin care. Massaging reddened areas is not helpful because blood vessels are already dilated; massage may be harmful ifischemic injury is present. The substances that leak into the interstitial spaces following tissue injury may further damage tissue; massage may force these substances into adjacent tissues.
Treatment Truths Advances have been made in the management of the wound environment as well as in the management of surface pressure through technology. The process of wound healing is an orderly pyramid of events and should be the cornerstone on which topical wound care is based(l 5). Wound repair consists of essential biochemical and cellular activities, and the goal of topical therapy is to create an optimum environment for the wound so these processes can occur unimpeded, if not enhanced. An Optimum wound environment is free of nonviable tissue; has no clinical infection, no "dead space," and no excess wound exudate; has a moist wound surface; and allows adequate wound bed oxygenation. Topical therapy today is designed to support moist wound healing, be nontraumarie to healthy tissue, and reduce or eliminate pain. One of the biggest changes in pressure ulcer care is the process used to select the appropriate wound care product. A nurse considers the characteristics of the wound--for example, location, depth, tissue, and exudate--condition of the surrounding skin, the patient's general health, the cost-benefit of the product o(procedure, the frequency of the dressing change, and efficient use of such limited resources as nursing time. Clearly, effective wound care requires appropriate selection of topical dressings and accurate wound assessments. In the past there has been much discrepancy in the terms used to describe pressure ulcers. It is now imperative that nurses acquire accurate assessment skills and use terms appropriately. (See "Using the Right Term, ""at left.) Considerable research has been conducted to create wound care products that support the wound re-
Geriatric Nursing July/August 1990 183
CHOOSINGTHE PROPER
TI~mSP~I~ O~ESS~G
TRANSPARENTDRESSING 8ioclusive (Johnson & Johnson); Op-Slte (United Smith & Nephew); Tegaderm (3-M)
adhesive; moisture and vapor permeable; occlusive membrane that traps exudate against wound
traps leukocyte and macrophage-rich exudate against wound, creating moist environment and promoting autolysis
HYDROCOLLOID WAFERS
adhesive; produces occlusive ge( where it makes contact with wound exudate
same as transparent dressing
nonadhesive; available in pastes, powders, nonwoven sheets
absorbs exudate; conforms to wound bed; nonocclusive; can be used in combination with other dressings
HYDROGELS Intrasite gel (United Smith & Nephew); Vigilon (Bard); Geliperm (Fougera)
nonadhesive; composed of water imbedded in polyethylene oxide or a starch-based eopolymer powder; available as wafer, gel, powder mixture
conforms to wound bed; nonadhesive; nonocclusive can be placed in deep or shallow wounds with cellulitis; provides moisture to promote resurfacing of granular wounds and liquefaction of nonviable tissue
POLYURETHANE FOAM DRESSINGS
nonadhesive; hydrophyllic
nonocclusive; can be used with wound fillers; absorbs exudate; appropriate for wounds with cellulitis
nonadhesive; dry; various square sizes and ribbon strips
readily available and inexpensive
Comfeel (Coloplast); DuoDerm (ConvaTec); Restore (Holllster) ABSORPTIVE WOUND FILLERS
Comfeel Ulcer Paste (Coloplast); DuoDerm granules (ConvaTec);Kaltostat (Calgon Vestal Lab.)
HYOROCOLLOIDWAFER
A~9ORPTIVEWOUNDq~LLER
Allevyn(United Smith & Nephew); Cutinova(Biersdorf); Lyofoam(Acme United) GAUZE DRESSINGS
HYDROGEL
pair process. This cumulatice effort means that today we have over 2000 wound care products on the market. (See "'Choosing the Proper Wound Care Products, "' above.) Many topical solutions and gels are on the market for wound care, including Carrington gel (Carrington Lab.), Biolex Granulating Gel (Bio-
184 Geriatric Nursing July/August 1990
Catalina), and DermaGran Wound Spray (DermaSciences). All of these products can be used in combination with any of the contemporary wound covenngs. Ingredients in these solutions and gels include aloe or aloe extracts, vitamins, and minerals, all of which are thought to stimulate cellular activity(l 6).
Wound cleansers, antiseptics, and antimicrobials have also undergone intense scrutiny in the past few years. Povidone-iodine, hexachlorophene, 3 percent hydrogen peroxide, 0.25 percent acetic acid, and 0.05 percent sodium hypochlorite are just a few solutions that have been used to rid pressure ulcers o f surface contami-
VOUND CARE PRODUCTS ~isadvantages
Indicated for wounds
Contraindicated for wounds
Use tips
does not fill dead space; is adhesive; fluid that collects under dressing may be mistaken as indication of infection
stage 1, 2, or shallow 3; clean/granular; with shallow necrosis; small amount of slough
suspected or known to be infected; with heavy exudate
loose, leaks, or if fluid
same as transparent dressing
same as transparent dressing
same as transparent dressing
same as transparent dressing
requires second cover dressing to secure
stage 2or3; deep; exuding
with deep tunnels; without exudate
frequency of change varies from daily to twice a week, depending on exudate amount and type of dressing over filler
may be difficult to manipulate; can macerate intact surrounding skin; must be secured in place with gauze or foam; occlusive dressings can be used to secure when cellulitis is not suspected; limited absorption
stage 2 or 3; granular or with shallow eschar
w i t h deep tunnels or undermining
usually require daily changes because dressing dehydrates
must be secured in place
stage 2 or 3; with minimal to moderate amount of exudate
without exudate
no special requirements
labor intensive due to frequent remoistening required; difficult to ensure optimum wound environment; must be secured in place; cat'egivers confuse cotton-filled dressing sponges for gauz e
large and gaping; cellulitis
none
keep moist with normal saline; avoid cotton-filled sponges
nants. However, these products h a v e cytotoxic effects to healthy tissue that are completely at odds with the goal of optimizing the wound environment(17). In fact, some research suggests that use ofpovidone-iodine in wounds actually raises the risk of developing a wound infection. Physiologic solutions such as normal sal-
ine will probably become the solutions of choice for wound irrigations in the 1990s. Most past and current pressure ulcer care products ate passive and do not interact with the wound. Products are now being developed that are intended to stimulate specific steps of the wound-repair process.
change dressing when it is contacts healthy skin
Growth factors, for example, are cellular products (most often protein) that are released from platelets or produced by wounded tissue. As these are identified, their role in processes such as angiogenesis, epithelial cell migration, and fibroblast activity is being recognized(18). Commercially, growth factors are avail-
Geriatric Nursing July/August1990185
able in selected centers with physician supervision. The growth factor solution is usually applied once per day and covered with a nonadherent dressing. It is believed to be most appropriate for chronic ulcers. Electrical stimulation and hyperbaric oxygen are techniques that have been Studied off and on for the past ten years b u t h a v e b e e n slow to gain acceptance in clinical-prac~tice. Unanswered questions still exist for both approaches. For example, the voltage, length ofpulsatlon s, and polarity are uncertain for electrical stimulation. The ~ideal length of-hyperbaric treatments is unknown at this time.(19) Debridement of wounds can now be accomplished in a number of ways besides the familiar surgical technique(20). The focus ofdebridement is to selectively destroy nonviable tissue and preserve viable granulating tisues. High-pressure irrigations are effective(21). Moist wound healing techniques in and of themselves allow for autolysis to occur(22). Whirlpool therapy probably debrides by both mechanical action and hydration of nonviable tissue, but it should be reserved for only the large pressure ulcers. Whirlpool therapy dehydrates surrounding tissue and is resource intensive, requiring a great deal of both manpower and time. Now CO'- lasers are being used to vaporize necrotic tissue quickly • and painlessly, sterilize the wound, and stimulate the release of growth factors(23). All of these new developments mean that older treatments must be phased out. Heat lamp is one such therapy that can be laid to rest. Besides creating a dessicated wound, it exaggerates the inflammatory phase and delays the subsequent woundrepair processes. Antacids and scarlet red ointment can still be found in some wounds despite their lack ofetficacy and scientific basis. Berecek wrote an excellent review of wound care providing a possible rationale for the use of sugar and honey in wounds(24). However, the state of the art of pressure ulcer management is such that this, too, should be discarded. Gauze has in the past been used in
1 8 6 G e r i a t r i c N u r s i n g J u l y / A u g u s t 1990
wounds dry, wet-to-dry, and continuously moist. It should now be evident that dry and wet-to-dry dressings against a wound bed violate moist wound healing principles and are destructive to both viable and nonviable tissue. The list of products once used on pressure ulcers is endless. Our chal lenge is to ask: Does this intervention support moist wound healing principles? Does it have sound scientific rationale? And does it use resources efficiently? If the answer to these ques-
Massaging reddened areas over bony prominences is no longer considered appropriate skin care. tions is not clear, the treatment should lie re'considered.
Avoiding Surface Pressures Probably the biggest change that has occurred in surface pressure management is the introduction of high-tech specialty beds. These are air-filled or air-fluidized beds designed to relieve the pressure between the bed surface and the patient so that occlusion of blood vessels does not occur. While these beds appear to be quite effective in relieving pressure, specialty beds are costly and may limit patient mobility. Ideally, they should be used only as a temporary intervention. Many improvements have also been made in pressure-reducing devices. These are primarily mattress overlays or chair pads that redistribute pressure over a large surface area. They consist of dense convo"luted foam, air, water, gel, and combinations of these. A great variety now exist and they can be used for patients with pressure ulcers as long as the patient and staff are able to comply with regular repositioning. Pressure-reducing devices can also be used as maintenance devices when a specialty bed is no longer indicated, in other words, when the ulcer is healing and/or the patient is more mobile.
References I. Norton, D.,andothersAnhwestigationofGeriat. tic Nursing Problems in ttospitals. London: Nation Corporation for the Care of Old People, 1962. 2. Gosnell, D.J. An assessment tool to identify pressure sores. Nurs. Res. 22:55-59, 1973. 3• Bergstrom, N., and others. The Braden Scale for Predicting Pressure Sore Risk. Nuts. Res. 36:205210, July-Aug. 1987. 4. Velez-Campos, L., and Mahoney, P. DRGs and pressure sores: ~hat is reimbursable and v, hat is not. J. Enterostomal Ther. 14:243-247, Nov.Dee., 1987. 5. 8raden, B.J., and Bergstrom, N. Clinical utilityof the Bradcn Scale for Predicting Pressure Sore Risk. Decubitus 2:44.-.46,50-51, Aug. 1989. 6• Bergstrom, N., and others. A clinical trial of the Braden Scale for Predicting Pressure Sore Risk. Nuts. Clin. A'orth Am. 22:417-418, June 1987. 7. Ta)lor, K.J., and others. Assessment tools for the identification of patients at risk for the development of pressure sores. .I. Enlerostomal Ther.15:2O I-2OS, scpt.-Oct. 1988. 8. Bergslrom, N., and Braden, B. The Influence of Diminished Tissue Tolerance on Pressure Sore Development in the Elderly. Paper presentation at the 40th Annual Scientific Meeting of the Gerontological Society, held in Washington, DC, in No•,'ember 1987. (Abstract printed in The Gerontologist, 27). 9. Schmid-schonbein, H., and others. Blood fluidity as a consequence of red cell fluidity: flow propcrties ofblood and flow behavior of blood in vascular diseases. Angiology 31:301-309, 1980. 10. Anderson, T.P., and Andberg, M. M. Psychosocial factors associated with pressure sores. Arch. Phys. Med. Rehabil. 60:341-346, 1979. I I. Braden, B.J. Emotional stress and pressure sore formation among the elderly recently relocated to a. nursing home. In KeyAspects ofRecofer):, bnproving Mobility Rest. and Nutrition. (To be published). 12. Lamid, S., and El Ghatit, A.Z. Smoking, spasticity and pressure sores in spinal cord injured patients. Am. J. Phys. ,lied. 62:300-306, Dec. 1983. 13. Bryant, R. Wound repair:, a review• J. Enternatihal Ther. 14:262-266 Nov.-Dec., 1987. 14. Muldcr, G.D., and LaPan, M. Decubitus ulcers: update on new approaches to treatment• Geriatrics 43:37-39, 44--45, 49-50, Sept• 1988. 15. Alterescu, V. Toward a physiologic approach to •the topical treatment ofopened wounds. J. EnterostomalTher. 10:101-107, 1983. 16. Jackson, D.S., and Royce, D.T. Current concepts in wound healing: research and theory. J. Enterostomal Ther. 15:133-137, May-June 1988. 17. Lineawcaver, W., and others. Topical antimierobial toxicity• Arch. Surg. 120:267-270, Mar. 1985. 18. Kavchak-Keyes, M.A. Treating decubitus ulcers using four proven steps. Nursing 1977 7:44-45, Oct.1977. 19. International Association for Enterostomal Therapy. The Standard of Care for Dermal l~bunds: Pressure Sores." lrvine, CA: The Association, 1987. 20: Kr°usk°P' T'A" and °thers" Effectiveness °fmat" tress overlays in reducing interface pressures during recumbency. J. Rehabil. Res. Dev.22:7, July 1985. 21. Rogness, H. High-pressure wound irrigation: J. Enterostomal Ther• 12:27-28, 1985. 22. Witkowski, J.A., and Parish, L.C. Cutaneous ulcer therapy. Int. J. Dermatol. 25:420--426, 1986. 23. Juri, H•, and Palma. J.A.: CO 2 laser in decubitus ulcers: a comparative study. Lasers Surg. ,lied. 7(4):296-299, 1987. 24. Berecek, K.H. Treatment of decubitus ulcers. Nuts. Clin. A'orthAm. 10:171-210, 1975.
"V 'Y V ' v V "V V 'Y V V V ' ~ " V ' V 'Y V ' T Y 'Y ~
The '80s brought refinements in assessment, plus a wave of new products and techniques. Is your practice up to date? BARBARA J. BRADEN RUTH BRYANT ' n reviewing how the art and science of preventing and treat. ing pressure ulcers has changed over the past 10 years, one is struck by the dichotomy: Little has changed and yet much is radically different. Practice has.been slow to catch up with science in some areas and has raced ahead in others. Changes in our knowledge of factors that contribute to pressure ulcers have heightened our ability to identify those at risk for developing them. And our refined knowledge guides our strategies for preventing ulcers as well as hastening wound healing when a pressure ulcer develops.
l
Who Is At Risk? Nurses have long appreciated the need for a reliable way to assess patient risk for pressure ulcer development: The first tool, the Norton Scale, developed by Doreen Norton, a British nurse, has served as a model for all subsequent assessment tools, including the Gosnell Scale in 1973 and the Braden Scale in 1987 (1-3). While the Norton tool has been Barbara J. Braden, RN, PhD, is an associate professor of gerontological nursing at Crcighton University School of Nursing, Omajla, NE. She has been involved in research and development of the Braden scale for predicting pressure ulcers and was project director of Creighton University Teaching Nursing Home Project. Ruth Bryant, R N, MSN, is director of the Enterostomal Therapy Nursing Education Program at Abbott Northwestern Hospital, Minneapolis, MN. She has been a practicing. enterostomal therapy nurse for 10 years and staffs a busy clinic.
182 Gerialrie Nursing July/August 1990
widely used in England, risk assess- tice has been to evaluate the patient ment has not disseminated in the only on admission. While this allows practice arena here. Until recent the nurse to identify those patients years, we seemed to expect nurses to who are at highest risk, it's not possiidentify those at risk from a gestalt of ble to learn enough during the admisroutine assessments. Outside forces sion assessment to identify lesser desuch as reimbursement, the nurse grees of risk accurately. Risk assessment should be repeatshortage, the expense of therapeutic beds, a n d the aging of the patient ed 24 to 48 hours following admispopulation are driving the change to sion and whenever the patient's con• dition changes thereafter. It is wise to assess more precisely. One force with which nurses in- specify in the nursing protocols an increasingly must reckon is reimburse- terval for reassessment that reflects ment under the current prospective the rapidity with which patient conpayment system for Medicare pa- ditions usually change in the given tients. Reimbursement under the setting. For example, one might set DRG is limited when a patient devel- the interval at daily in the intensive ops a pressure ulcer during hospitali- care unit, every 48 hours on medicalzation. Such an incident will trigger a surgical floors, weekly in skilled local Peer Review Organization re- nursing facilities, and monthly in inview of nursing services provided termediate care facilities. A number of factors that are not so during the patient's stay(4). The Joint Commission of Accredi- easily included in a risk score may tation of Hospitals Organization contribute to pressure ulcer developconsiders hospital-acquired pressure ment. These include low blood presulcers an indicator of poor care and sure and other hemodynamic expects evidence that a program to changes; elevated body temporature; prevent such occurrences is in place emotional stress; smokifig; and skin and working. Risk assessment is the temperature. Systolic blood pressures below 100 cornerstone of such a program. To assure care that is cost efficient, mm Hg and diastolic pressures below an assessment tool should be fairly 60 have been associated with existing accurate in predicting who will and pressure ulcers for a number of will not develop a pressure ulcer, and years(2). This level ofhypotension is different nurses should reliably ob- not unusual among the institutionaltain the same rating when assessing a ized elderly, and low diastolic prespatient. The Braden scale has proved sure has been found to be highly prevery accurate in identifying those dictive of pressure sore develop-. who will develop a pressure ulcer; it ment(8). It is especially important to also overpredicts less than other reduce surface pressure in elders with tools(5-7). The Braden scale takes sustained low blood pressures. Increased blood viscosity and high less than a minute to complete and hematocrit have also been associated can be used reliably by RNs. The prevailing assessment prac- with tissue damage(9). While dehy-
USING THE RIGHT TERM
dration has often been mentioned as predisposing a patient to pressure ulcer development, improving hydration rarely gets enough attention in preventive protocols. The association between elevated body temperature and pressure ulcer formation is not known, though it seems likely that the catabolic state accompanying infection plays some part(2,8). In elderly subjects, even a mild elevation may raise the risk for pressure ulcer development. Another recent developmenfis the association of psychosocial issues with pressure ulcer formation. Pressure ulcers have been linked to patients' low motivation and emotional energy to care for themselves and to the physiological changes that take place during emotional stress(10). There is also evidence of a link between the stress of relocation to a nursing home and superficial pressure ulcers occurring during the first month following admission(l 1). This and other findings regarding the timing of most pressure ulcer development within two weeks of ad• mission underscore the importance of intensive prevention in the early days following admission. It may also be appropriate to reformulate nursing home admission procedures to lower the stress that arises out of uncertainty and to promote a sense of l~rsonal control. Evidence that smoking may contribute to pressure ulcer formation is beginning to accumulate. Lamid and El Ghatit, in a study of spinal cord injured patients, found a significant positive correlation between cigarette smoking and the presence of pressure ulcers(l 2). These investigators also reported that the incidence and extent of existing ulcers were greatest in those patients with high pack-year histories.
Abandoning Prevention Myths Just as our ideas concerning risk factors and risk assessment have changed over the past ten years, so have our ideas concerning appropriate preventive measures(13,14). The oldest interventions in a nurse's armamentarium came under fire in the '80s: The standard turning schedule ofevery two hours has given way
Granule. pra~(~nce of smltll, bl(X~d vessels and cQnnect~e Us~u_e;wound, al~ pears r~d. grainy~.andm-oist
Cellulitis: ~yergrowlh of bavaria in wound creating Iocal~lgns,suchas eryo thema, drainage, and warmth Denude: loss of superficial tissue, epidermis Erythema: redness of skin surface produced by vasodHation Eschar:. Hard, black, crusted nonviable tissue
Excoriation: linear scratch marks Necrotic avascular, dead Nonvlablez (lead Slough: loose, stringy necrotio tissue Stage 1: erythema Stage 2: blister or tissue loss limited to epidermis or dermis Stage 3: tissue loss extending into subcutaneous tissue Stage 4: tissue loss extending into muscle. bone. or tendon Wound base: bed of wound Modified from Standards of Care, Dermal Wounds: Pressure Sores. Irvlne,CA, International Assooiation for Enterostomal Therapy, 1987.
to an individualized turning schedule planned ai'ound patient meals and care activities. And more frequent turning to a variety of positions, not just side-back-side, is now being encouraged. The recommended alternative to the lateral position is the 30-degree oblique position in which one can almost totally avoid pressure over bony prominences. A turn of only 30 degrees to the side also has the advantage that it can usually be done by one caregiver using a couple of pillows. The rule of only 30 degrees should also be applied to elevating the head of the bed. A slight elevation of the head of the bed may shift some pressure points, but .more elevation will cause increased pressure, friction, and shear. The practice of massaging reddened areas over bony prominences is no longer considered appropriate
skin care. Massaging reddened areas is not helpful because blood vessels are already dilated; massage may be harmful ifischemic injury is present. The substances that leak into the interstitial spaces following tissue injury may further damage tissue; massage may force these substances into adjacent tissues.
Treatment Truths Advances have been made in the management of the wound environment as well as in the management of surface pressure through technology. The process of wound healing is an orderly pyramid of events and should be the cornerstone on which topical wound care is based(l 5). Wound repair consists of essential biochemical and cellular activities, and the goal of topical therapy is to create an optimum environment for the wound so these processes can occur unimpeded, if not enhanced. An Optimum wound environment is free of nonviable tissue; has no clinical infection, no "dead space," and no excess wound exudate; has a moist wound surface; and allows adequate wound bed oxygenation. Topical therapy today is designed to support moist wound healing, be nontraumarie to healthy tissue, and reduce or eliminate pain. One of the biggest changes in pressure ulcer care is the process used to select the appropriate wound care product. A nurse considers the characteristics of the wound--for example, location, depth, tissue, and exudate--condition of the surrounding skin, the patient's general health, the cost-benefit of the product o(procedure, the frequency of the dressing change, and efficient use of such limited resources as nursing time. Clearly, effective wound care requires appropriate selection of topical dressings and accurate wound assessments. In the past there has been much discrepancy in the terms used to describe pressure ulcers. It is now imperative that nurses acquire accurate assessment skills and use terms appropriately. (See "Using the Right Term, ""at left.) Considerable research has been conducted to create wound care products that support the wound re-
Geriatric Nursing July/August 1990 183
CHOOSINGTHE PROPER
TI~mSP~I~ O~ESS~G
TRANSPARENTDRESSING 8ioclusive (Johnson & Johnson); Op-Slte (United Smith & Nephew); Tegaderm (3-M)
adhesive; moisture and vapor permeable; occlusive membrane that traps exudate against wound
traps leukocyte and macrophage-rich exudate against wound, creating moist environment and promoting autolysis
HYDROCOLLOID WAFERS
adhesive; produces occlusive ge( where it makes contact with wound exudate
same as transparent dressing
nonadhesive; available in pastes, powders, nonwoven sheets
absorbs exudate; conforms to wound bed; nonocclusive; can be used in combination with other dressings
HYDROGELS Intrasite gel (United Smith & Nephew); Vigilon (Bard); Geliperm (Fougera)
nonadhesive; composed of water imbedded in polyethylene oxide or a starch-based eopolymer powder; available as wafer, gel, powder mixture
conforms to wound bed; nonadhesive; nonocclusive can be placed in deep or shallow wounds with cellulitis; provides moisture to promote resurfacing of granular wounds and liquefaction of nonviable tissue
POLYURETHANE FOAM DRESSINGS
nonadhesive; hydrophyllic
nonocclusive; can be used with wound fillers; absorbs exudate; appropriate for wounds with cellulitis
nonadhesive; dry; various square sizes and ribbon strips
readily available and inexpensive
Comfeel (Coloplast); DuoDerm (ConvaTec); Restore (Holllster) ABSORPTIVE WOUND FILLERS
Comfeel Ulcer Paste (Coloplast); DuoDerm granules (ConvaTec);Kaltostat (Calgon Vestal Lab.)
HYOROCOLLOIDWAFER
A~9ORPTIVEWOUNDq~LLER
Allevyn(United Smith & Nephew); Cutinova(Biersdorf); Lyofoam(Acme United) GAUZE DRESSINGS
HYDROGEL
pair process. This cumulatice effort means that today we have over 2000 wound care products on the market. (See "'Choosing the Proper Wound Care Products, "' above.) Many topical solutions and gels are on the market for wound care, including Carrington gel (Carrington Lab.), Biolex Granulating Gel (Bio-
184 Geriatric Nursing July/August 1990
Catalina), and DermaGran Wound Spray (DermaSciences). All of these products can be used in combination with any of the contemporary wound covenngs. Ingredients in these solutions and gels include aloe or aloe extracts, vitamins, and minerals, all of which are thought to stimulate cellular activity(l 6).
Wound cleansers, antiseptics, and antimicrobials have also undergone intense scrutiny in the past few years. Povidone-iodine, hexachlorophene, 3 percent hydrogen peroxide, 0.25 percent acetic acid, and 0.05 percent sodium hypochlorite are just a few solutions that have been used to rid pressure ulcers o f surface contami-
VOUND CARE PRODUCTS ~isadvantages
Indicated for wounds
Contraindicated for wounds
Use tips
does not fill dead space; is adhesive; fluid that collects under dressing may be mistaken as indication of infection
stage 1, 2, or shallow 3; clean/granular; with shallow necrosis; small amount of slough
suspected or known to be infected; with heavy exudate
loose, leaks, or if fluid
same as transparent dressing
same as transparent dressing
same as transparent dressing
same as transparent dressing
requires second cover dressing to secure
stage 2or3; deep; exuding
with deep tunnels; without exudate
frequency of change varies from daily to twice a week, depending on exudate amount and type of dressing over filler
may be difficult to manipulate; can macerate intact surrounding skin; must be secured in place with gauze or foam; occlusive dressings can be used to secure when cellulitis is not suspected; limited absorption
stage 2 or 3; granular or with shallow eschar
w i t h deep tunnels or undermining
usually require daily changes because dressing dehydrates
must be secured in place
stage 2 or 3; with minimal to moderate amount of exudate
without exudate
no special requirements
labor intensive due to frequent remoistening required; difficult to ensure optimum wound environment; must be secured in place; cat'egivers confuse cotton-filled dressing sponges for gauz e
large and gaping; cellulitis
none
keep moist with normal saline; avoid cotton-filled sponges
nants. However, these products h a v e cytotoxic effects to healthy tissue that are completely at odds with the goal of optimizing the wound environment(17). In fact, some research suggests that use ofpovidone-iodine in wounds actually raises the risk of developing a wound infection. Physiologic solutions such as normal sal-
ine will probably become the solutions of choice for wound irrigations in the 1990s. Most past and current pressure ulcer care products ate passive and do not interact with the wound. Products are now being developed that are intended to stimulate specific steps of the wound-repair process.
change dressing when it is contacts healthy skin
Growth factors, for example, are cellular products (most often protein) that are released from platelets or produced by wounded tissue. As these are identified, their role in processes such as angiogenesis, epithelial cell migration, and fibroblast activity is being recognized(18). Commercially, growth factors are avail-
Geriatric Nursing July/August1990185
able in selected centers with physician supervision. The growth factor solution is usually applied once per day and covered with a nonadherent dressing. It is believed to be most appropriate for chronic ulcers. Electrical stimulation and hyperbaric oxygen are techniques that have been Studied off and on for the past ten years b u t h a v e b e e n slow to gain acceptance in clinical-prac~tice. Unanswered questions still exist for both approaches. For example, the voltage, length ofpulsatlon s, and polarity are uncertain for electrical stimulation. The ~ideal length of-hyperbaric treatments is unknown at this time.(19) Debridement of wounds can now be accomplished in a number of ways besides the familiar surgical technique(20). The focus ofdebridement is to selectively destroy nonviable tissue and preserve viable granulating tisues. High-pressure irrigations are effective(21). Moist wound healing techniques in and of themselves allow for autolysis to occur(22). Whirlpool therapy probably debrides by both mechanical action and hydration of nonviable tissue, but it should be reserved for only the large pressure ulcers. Whirlpool therapy dehydrates surrounding tissue and is resource intensive, requiring a great deal of both manpower and time. Now CO'- lasers are being used to vaporize necrotic tissue quickly • and painlessly, sterilize the wound, and stimulate the release of growth factors(23). All of these new developments mean that older treatments must be phased out. Heat lamp is one such therapy that can be laid to rest. Besides creating a dessicated wound, it exaggerates the inflammatory phase and delays the subsequent woundrepair processes. Antacids and scarlet red ointment can still be found in some wounds despite their lack ofetficacy and scientific basis. Berecek wrote an excellent review of wound care providing a possible rationale for the use of sugar and honey in wounds(24). However, the state of the art of pressure ulcer management is such that this, too, should be discarded. Gauze has in the past been used in
1 8 6 G e r i a t r i c N u r s i n g J u l y / A u g u s t 1990
wounds dry, wet-to-dry, and continuously moist. It should now be evident that dry and wet-to-dry dressings against a wound bed violate moist wound healing principles and are destructive to both viable and nonviable tissue. The list of products once used on pressure ulcers is endless. Our chal lenge is to ask: Does this intervention support moist wound healing principles? Does it have sound scientific rationale? And does it use resources efficiently? If the answer to these ques-
Massaging reddened areas over bony prominences is no longer considered appropriate skin care. tions is not clear, the treatment should lie re'considered.
Avoiding Surface Pressures Probably the biggest change that has occurred in surface pressure management is the introduction of high-tech specialty beds. These are air-filled or air-fluidized beds designed to relieve the pressure between the bed surface and the patient so that occlusion of blood vessels does not occur. While these beds appear to be quite effective in relieving pressure, specialty beds are costly and may limit patient mobility. Ideally, they should be used only as a temporary intervention. Many improvements have also been made in pressure-reducing devices. These are primarily mattress overlays or chair pads that redistribute pressure over a large surface area. They consist of dense convo"luted foam, air, water, gel, and combinations of these. A great variety now exist and they can be used for patients with pressure ulcers as long as the patient and staff are able to comply with regular repositioning. Pressure-reducing devices can also be used as maintenance devices when a specialty bed is no longer indicated, in other words, when the ulcer is healing and/or the patient is more mobile.
References I. Norton, D.,andothersAnhwestigationofGeriat. tic Nursing Problems in ttospitals. London: Nation Corporation for the Care of Old People, 1962. 2. Gosnell, D.J. An assessment tool to identify pressure sores. Nurs. Res. 22:55-59, 1973. 3• Bergstrom, N., and others. The Braden Scale for Predicting Pressure Sore Risk. Nuts. Res. 36:205210, July-Aug. 1987. 4. Velez-Campos, L., and Mahoney, P. DRGs and pressure sores: ~hat is reimbursable and v, hat is not. J. Enterostomal Ther. 14:243-247, Nov.Dee., 1987. 5. 8raden, B.J., and Bergstrom, N. Clinical utilityof the Bradcn Scale for Predicting Pressure Sore Risk. Decubitus 2:44.-.46,50-51, Aug. 1989. 6• Bergstrom, N., and others. A clinical trial of the Braden Scale for Predicting Pressure Sore Risk. Nuts. Clin. A'orth Am. 22:417-418, June 1987. 7. Ta)lor, K.J., and others. Assessment tools for the identification of patients at risk for the development of pressure sores. .I. Enlerostomal Ther.15:2O I-2OS, scpt.-Oct. 1988. 8. Bergslrom, N., and Braden, B. The Influence of Diminished Tissue Tolerance on Pressure Sore Development in the Elderly. Paper presentation at the 40th Annual Scientific Meeting of the Gerontological Society, held in Washington, DC, in No•,'ember 1987. (Abstract printed in The Gerontologist, 27). 9. Schmid-schonbein, H., and others. Blood fluidity as a consequence of red cell fluidity: flow propcrties ofblood and flow behavior of blood in vascular diseases. Angiology 31:301-309, 1980. 10. Anderson, T.P., and Andberg, M. M. Psychosocial factors associated with pressure sores. Arch. Phys. Med. Rehabil. 60:341-346, 1979. I I. Braden, B.J. Emotional stress and pressure sore formation among the elderly recently relocated to a. nursing home. In KeyAspects ofRecofer):, bnproving Mobility Rest. and Nutrition. (To be published). 12. Lamid, S., and El Ghatit, A.Z. Smoking, spasticity and pressure sores in spinal cord injured patients. Am. J. Phys. ,lied. 62:300-306, Dec. 1983. 13. Bryant, R. Wound repair:, a review• J. Enternatihal Ther. 14:262-266 Nov.-Dec., 1987. 14. Muldcr, G.D., and LaPan, M. Decubitus ulcers: update on new approaches to treatment• Geriatrics 43:37-39, 44--45, 49-50, Sept• 1988. 15. Alterescu, V. Toward a physiologic approach to •the topical treatment ofopened wounds. J. EnterostomalTher. 10:101-107, 1983. 16. Jackson, D.S., and Royce, D.T. Current concepts in wound healing: research and theory. J. Enterostomal Ther. 15:133-137, May-June 1988. 17. Lineawcaver, W., and others. Topical antimierobial toxicity• Arch. Surg. 120:267-270, Mar. 1985. 18. Kavchak-Keyes, M.A. Treating decubitus ulcers using four proven steps. Nursing 1977 7:44-45, Oct.1977. 19. International Association for Enterostomal Therapy. The Standard of Care for Dermal l~bunds: Pressure Sores." lrvine, CA: The Association, 1987. 20: Kr°usk°P' T'A" and °thers" Effectiveness °fmat" tress overlays in reducing interface pressures during recumbency. J. Rehabil. Res. Dev.22:7, July 1985. 21. Rogness, H. High-pressure wound irrigation: J. Enterostomal Ther• 12:27-28, 1985. 22. Witkowski, J.A., and Parish, L.C. Cutaneous ulcer therapy. Int. J. Dermatol. 25:420--426, 1986. 23. Juri, H•, and Palma. J.A.: CO 2 laser in decubitus ulcers: a comparative study. Lasers Surg. ,lied. 7(4):296-299, 1987. 24. Berecek, K.H. Treatment of decubitus ulcers. Nuts. Clin. A'orthAm. 10:171-210, 1975.
