Clinical Practice Guideline (CPG) for Pressure Ulcers. For Practitioners. What is a Pressure Ulcer?. Definition: A pressure ulcer is a localized injury to the skin or underlying tissue, usually over a bony prominence, that is a result of pressure or of pressure combined with shear or friction.
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(Adapted from CMS, 2007)
A pressure ulcer should be assessed in the context of the patient’s overall clinical, functional, and cognitive status.
Suspected deep tissue injury
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear*. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.Further description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark ulcer bed. The ulcer may further evolve and become covered by thin eschar*. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.
Intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk).
Effective management of a pressure ulcer requires:
Under the surveyor guidance accompanying F314, an unavoidable pressure ulcer is a pressure ulcer that develops even though a facility has done the following:
The following clinical circumstances, among others, may impede or prevent healing or result in additional ulcer development that may be unavoidable:
Pain management. After assessing pain and defining its characteristics (e.g., frequency, intensity, possible aggravating factors) and causes, treat it aggressively by using appropriate pain management protocols. (See AMDA’s 2003 clinical practice guideline, Pain Management in the Long-Term Care Setting
Proper positioning, turning, and transferring techniques are important to manage pressure and shearing forces, ensure weight redistribution on support surfaces, and protect uninvolved skin. Evidence does not support any specific time interval for turning patients as a preventive or healing strategy for pressure ulcers
A systematic review of support surfaces for pressure ulcer prevention found that the use of ordinary foam mattresses (less than 4 inches thick) presented a higher risk of pressure ulcer development than the use of higher-specification mattresses.45 Patients at risk of skin breakdown should be placed on a static support surface (e.g., foam overlay, foam mattress, static flotation device) rather than on a standard mattress.
Pressure ulcer healing may be delayed by the presence of necrotic tissue, which also provides a medium for bacterial growth. Any necrotic tissue observed during assessment of the ulcer should be debrided, provided that this intervention is consistent with overall patient care goals.
When choosing a debridement method, consider
It is generally recommended not to debride heel ulcers with dry, hard eschar unless there is edema, erythema, fluctuance, or drainage. Monitor heel ulcers closely for evidence of infection, at which time debridement should occur.
An effective antiseptic should:
The goals of dressing an ulcer are to:
Weekly or Dressing Change Monitoring