Care Tips for Chronic Wounds: Pressure Ulcers

Three months ago, Mrs J, 79, had a cerebrovascular accident (CVA) that left her unable to move. When she was discharged home, her skin was intact. Now she has been readmitted to the hospital with an unstageable sacral pressure ulcer (PrU).

On discharge from the first hospitalization, Mrs J's daughter bought a pressure-reducing mattress for her mother's bed; however, she did not obtain a chair cushion. In the last few weeks, Mrs J has spent most of the day sitting in a chair without pressure relief. Because the daughter was focusing on postCVA care and exercise, she failed to recognize the early signs of skin breakdown. When she did notice the wound, she attempted to pad it with gauze dressings from the local pharmacy. She then noticed an odor coming from her mother's wound, which prompted her to call her mother's health care provider; this led to the present hospital admission.

PATIENT EVALUATION

Designing a clinical pathway for PrU management begins with a comprehensive assessment of the patient and the wound. First, perform a risk assessment to determine the patient's PrU risk. Although numerous risk assessment tools are available, the Braden Scale (http://www.bradenscale.com) is the one most commonly used in the United States. Depending on the facility's standards, risk assessment may be done on each admission, readmission, or level of care change. The information gathered in the risk assessment will help in determining the optimum pressure-relieving device.

Other assessment tools, such as nutritional assessments, may be used in conjunction with the PrU risk assessment tool to develop a comprehensive plan of care. In addition, determine if the patient tried to treat the PrU at home, indicating which topical interventions have and have not been effective for the patient.
Mrs J's PrU is unstageable: Its depth is indeterminate because the wound is covered with a moist eschar and marginal slough. The eschar seems to have pulled away from the wound's edge between 6 and 8 o'clock; the wound margins also appear detached from the wound bed in this area, indicating tunneling.

Because of the adherent eschar, it is impossible to assess whether the wound margins are intact around the remaining perimeter. The wound has a pungent odor and purulent drainage. The periwound skin is reddened and warm, which may indicate a wound infection (see Infection: A Complication). Mrs J denies pain at the wound site, and she does not have an elevated temperature. The wound, but not the necrotic tissue, is cultured. No other areas of skin breakdown are apparent.
After completing the patient and wound assessment (see Advice on Documentation), a plan of care that is customized to the patient's needs can be created. In Mrs J's case, the health care provider schedules surgical wound debridement in the operating room. Debriding the devitalized tissue will allow the underlying healthy tissue to regenerate.

INTERVENTIONS

Debridement has revealed a Stage III PrU (see Staging Pressure Ulcers). The wound's odor and the redness of the periwound skin have dissipated; there's no evidence of a wound infection. In addition, the wound culture shows no signs of infection.

Tunneling is noted around the wound, with moderate serosanguineous drainage. The base of the wound is filled with healthy red granulation tissue. An alginate rope is loosely packed into the tunneled areas, and an alginate pad is fluffed into the wound base. The alginate will absorb up to 20 times its weight; therefore, it can be changed just once daily. The alginate is covered with a dry dressing and secured with a retention tape that is chosen for its gentleness to the periwound skin.Topical wound management should be reevaluated with each dressing change.

Because of the wound's severity and Mrs J's immobility, a low-air-loss (pressure-reducing) specialty bed is ordered for pressure relief. Mrs J is permitted to sit in a chair only for meals; the rest of the time she must remain in bed to keep pressure off her wound. A clinician from the hospital's rehabilitation service evaluates Mrs J for a seating device, and a dietitian assesses her nutritional status.
General advice for managing a PrU, regardless of stage, includes the following:

* Use normal saline solution or an appropriate cleansing agent to clean the PrU.

* Apply a topical prescriptive treatment or dressing that will maintain a moist healing environment based on the exudate amount or tissue type.

* Do not use drying treatments, such as heat lamps or antacids.

* Place the patient on an appropriate pressure-relieving device to keep pressure off the wound.

* Change the patient's position as needed, at least every 2 hours while the patient is in bed and every 15 minutes while he or she is sitting in a chair.

* Complete a comprehensive nutritional assessment, screening the patient for nutritional deficiencies.

Patient education should include the importance of regular skin assessments and the significance of reddened areas of skin. Provide printed educational material on skin assessment that the patient can refer to at home. In addition, discuss the use of pressure-relieving devices, turning and positioning, and nutritional screenings. Finally, arrange for home health care follow-up visits.

by Hess, Cathy Thomas