1. health and fitness
2. disease

NPUAP-EPUAP Pressure Ulcer
Prevention & Treatment Guidelines
[
[
Janet Cuddigan, PhD, RN, CWCN
Associate Professor & Department Chair
University of Nebraska Medical Center
Omaha, NE USA
Editor-in-Chief, EPUAP-NPUAP Guideline
Walk Through the Treatment
Guidelines with Us!
©NPUAP & EPUAP, 2009
2
Treatment Topics
• Classification
• Assessment & Monitoring Healing
• Nutrition for Healing
• Pain Assessment & Management
• Support Surfaces
• Cleansing
• Debridement
• Dressings
• Assessment & Treatment of Infection….
©NPUAP & EPUAP, 2009
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Treatment Topics
• Biophysical Agents
• Biological Dressings
• Growth Factors
• Surgery for Pressure Ulcers
• Pressure Ulcer Management in
Individuals Receiving Palliative Care
©NPUAP & EPUAP, 2009
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Treatment Topics
©NPUAP & EPUAP, 2009
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Classification of Pressure Ulcers
• New Components
– Use validated system
• NPUAP Staging & EPUAP Grading
• NPUAP-EPUAP International System
– Educate professionals (B)
– Confirm inter-rater reliability (B)
– Do not classify pressure ulcers on mucous
membranes
©NPUAP & EPUAP, 2009
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Educate professionals about special assessment
techniques in individuals with darkly pigmented skin. (B)
1. Skin Intact: Stage I and suspected deep tissue injury
may be difficult to detect with visual inspection alone.
Assess differences in skin temperature, skin color,
tissue consistency (i.e. boggy or firm) and pain
between affected areas and normal tissue.
2. Skin Open: Inflammatory redness of the surrounding
skin may be difficult to detect in Stage II through IV
pressure ulcers. Assess for heat, tenderness, pain or
change in tissue consistency to identify the extent of
inflammation and possible cellulitis and/or
undermining.
•
Baumgarten M, Margolis D, van Doorn C, Gruber-Baldini AL, Hebel JR, Zimmerman S, et
al. Black/White differences in pressure ulcer incidence in nursing home residents. J Am
Geriatr Soc. 2004 Aug;52(8):1293-8
©NPUAP & EPUAP, 2009
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Stage/Category II - IV
©NPUAP & EPUAP, 2009
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NPUAP-EPUAP International
Classification System©
• We agree on:
– Definition of pressure ulcers
– Definition of four “stages, grades, or
categories”
– Additional categories for USA
• Suspected Deep Tissue Injury
• The “Unstageables”
– Stage? Grade? Category?
©NPUAP & EPUAP, 2009
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I: Non-blanchable erythema of intact
skin
Intact skin with nonblanchable erythema
of a localized area
usually over a bony
prominence.
Discoloration of the
skin, warmth, edema,
hardness or pain may
also be present.
Darkly pigmented
skin may not have
visible blanching.
©NPUAP & EPUAP, 2009
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II: Partial thickness skin loss or
blister
• Partial thickness loss of
dermis presenting as a
shallow open ulcer with a
red pink wound bed,
without slough. May also
present as an intact or
open/ruptured serum or
sero-sanguinous-filled
blister.
©NPUAP & EPUAP, 2009
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III: Full thickness skin loss
• Full thickness skin
loss. Subcutaneous fat
may be visible but
bone, tendon or
muscle are not
exposed. Some slough
may be present. May
include undermining
and tunneling.
©NPUAP & EPUAP, 2009
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IV: Full thickness tissue loss
• Full thickness tissue
loss with exposed
bone, tendon or
muscle. Slough or
eschar may be
present. Often
includes undermining
and tunneling.
©NPUAP & EPUAP, 2009
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Full thickness skin or tissue loss –
Depth unknown
• Full thickness tissue
loss in which actual
depth of the ulcer is
completely obscured
by slough (yellow,
tan, gray, green or
brown) and/or eschar
(tan, brown or black)
in the wound bed.
©NPUAP & EPUAP, 2009
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Suspected deep tissue injury –
depth unknown
• 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.
©NPUAP & EPUAP, 2009
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Assessment & Monitoring Healing
• New Components
– Holistic patient assessment
– Pressure ulcer assessment (at least weekly)
– How to measure (B)
– Expect some signs of healing in 2 weeks (B)
– Assessment findings should guide treatment
– Changing assessment → changing treatment
– Assess progress toward healing with a validated tool
(B)
• Bates-Jensen Wound Assessment Tool (BWAT)
• Pressure Ulcer Scale for Healing (PUSH)
©NPUAP & EPUAP, 2009
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Nutrition for Pressure Ulcer Healing
• Most patients with PU suffer from
undernutrition
• Nutritional requirements usually
increase to support PU healing.
• Assess nutritional status
– Mini-Nutritional Assessment (MNA) validated & easy to use in
multi-morbid geriatric patients.
– MUST (Malnutrition Universal Screening Tool) – to ID risk of
undernutrition
– Child: assess weight, height, head circumference, body mass
index, skin fold plot, compare to age
– Miffin-St Jeor equation for bariatric patients
©NPUAP & EPUAP, 2009
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Nutrition for Pressure Ulcer Healing
• Provide sufficient nutrients & fluids.
– Kilocalories (B) (30- 35 kcal/kg/day)
– Protein to promote anabolism (B) (1.25 – 1.5
gm/kg/day). Assess renal function
– Vitamins & minerals with balanced diet;
supplements with deficiencies. (B)
– Enhanced foods or oral supplements (B)
– Fluids. Assess for dehydration.
(Hartgrink, et. al, 1998; Lee, et al, 2006; Langenkamp-Henken,
et al, 2000; Langer, et al, 2003)
©NPUAP & EPUAP, 2009
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Pain Assessment & Management
• Minimal evidence for management of PrU
pain
• Individuals with a PrU experience pain;
individuals with a Stage IV PrU experience
greater pain than those with ↓stage PrU
• Only 2% of patients in 1 study who
reported PrU pain had received timely
analgesia after c/o pain (Dallam et al.,
1995)
©NPUAP & EPUAP, 2009
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Pain Assessment & Management
• Assess for pain
• Prevent pain
• Manage general pain
• Reduce debridement pain
• Manage chronic pain
• Educate Individuals, Family and
Professionals
©NPUAP & EPUAP, 2009
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Prevent Pain
- Avoid postures that increase
pressure, such as Fowlers >30° or
90° side lying position, or the semirecumbent position.
-Use dressings less likely to cause
pain (HD, HDG, hydrofiber, alginates, foam,
polymeric foam, soft silicone, ibuprofenimpregnated [not available everywhere]).
©NPUAP & EPUAP, 2009
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Local Treatment of Pain
• Consider topical opioids
(diamorphine or benzydamine 3%) to
reduce or eliminate PU pain. (B)
– Topical anesthetics act on opioid receptors in
peripheral nerves that are activated during
inflammation
– Morphine or Diamorphine gel, foam dressing with
ibuprofen [not available everywhere]
(Flock, et al, 2003; Twillman, et al, 1999; Gottrup, et
al, 2007)
©NPUAP & EPUAP, 2009
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Chronic Pain
- For chronic pain, follow the World
Health Organization Dosing Ladder
- Refer the individual with chronic
pain related to PU to the appropriate
pain and/or wound clinic resources.
©NPUAP & EPUAP, 2009
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Support Surfaces for Treatment of
Pressure Ulcers
• New Components
– S3I Terms & Definitions
– Pressure Redistribution
– Growing Appreciation of Microclimate
• Local tissue temperature & moisture at bodysupport surface interface.
– Need for Standards: ISO Initiative
– Need to match patient needs to support
surface features
©NPUAP & EPUAP, 2009
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The term, “upgraded support surface” is used throughout this document to prompt the professional to consider replacing the existing support surface
only one of several strategies. The individual and pressure ulcer should be re-evaluated. Preventive interventions and local wound care should also b
Support Surfaces for Treatment of
Pressure Ulcers
• Replace the existing support surface with one
that provides better pressure redistribution if the
individual
–
–
–
–
–
can’t be turned off the ulcer,
has PU on 2 or > surfaces,
fails to heal or shows deterioration, I
is at hi risk for additional PU, or
bottoms out on existing surface.
©NPUAP & EPUAP, 2009
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The term, “upgraded support surface” is used throughout this document to prompt the professional to consider replacing the existing support surface
only one of several strategies. The individual and pressure ulcer should be re-evaluated. Preventive interventions and local wound care should also b
Support Surfaces for Treatment of
Pressure Ulcers
• When pressure ulcers deteriorate or fail to heal,
changing the support surface is only one of
several strategies. The individual and pressure
ulcer should be re-evaluated. Preventive
interventions and local wound care should also
be changed as needed.
©NPUAP & EPUAP, 2009
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The term, “upgraded support surface” is used throughout this document to prompt the professional to consider replacing the existing support surface
only one of several strategies. The individual and pressure ulcer should be re-evaluated. Preventive interventions and local wound care should also b
Support Surfaces for Treatment of
Pressure Ulcers
• General recommendations
– Support surfaces
– Positioning
• Support surfaces for:
•
•
•
•
Stage I & II (bed & chair)
Stage I & II of heels
Deep tissue injury
Stage III, IV & unstageable (bed & chair, heels)
©NPUAP & EPUAP, 2009
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The term, “upgraded support surface” is used throughout this document to prompt the professional to consider replacing the existing support surface
only one of several strategies. The individual and pressure ulcer should be re-evaluated. Preventive interventions and local wound care should also b
Support Surfaces for Treatment of
Pressure Ulcers
• Special Populations
– Critically ill
• Hemodynamic instability
– Spinal cord injury
– Bariatric
• Fit individual to bed at admission
©NPUAP & EPUAP, 2009
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Wound Bed Preparation and
Biofilms
• Guiding Principles of Wound Bed
Preparation
–
–
–
–
Tissue
Infection/ inflammation
Moisture
Epithelium/edges
Schultz GS, Sibbald RG, Falanga V, Ayello EA, Dowsett C, Harding K, Romanelli M,
Stacey MC, Teot L, Vanscheidt W. Wound bed preparation: a systematic approach
to wound management. Wound Repair Regen 11 Suppl 1:S1-S28, 2003
©NPUAP & EPUAP, 2009
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Cultures & Biofilms
• Do standard specimen processing
procedures detect biofilms and the organisms
encased in biofilms?
• How do we remove biofilms?
• Once removed, how to we prevent biofilms
from re-forming?
©NPUAP & EPUAP, 2009
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How Do Bacterial Biofilms Form?
Five stages of biofilm development in Pseudomonas aeruginosa. In Stage 1, bacterial cells attach reversibly to the
surface. At Stage 2, the cells attach irreversibly, mediated by exopolymeric substances, and loose flagella-driven
motility. In Stage 3, the first biofilm architecture occurs, forming microcolonies, while in Stage 4 the fully mature
biofilm architecture is achieved. In Stage 5, dispersion of single motile cells occurs from the mature biofilm, which
‘seed’ other surfaces, re-initiating the process. Graphic and photos by Peg Dirckx, David Davies and Karin Sauer
©NPUAP & EPUAP, 2009
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Cleansing
• New Components
– Cleanse pressure ulcer & surrounding skin
(B)
– Normal saline or potable water
– Consider solutions with surfactants and
antimicrobials with
• Debris
• Confirmed or Suspected Infection
• High levels of bacterial contamination
– Konya, et al. 2005
©NPUAP & EPUAP, 2009
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Debridement
• Debride devitalized tissue when appropriate to
individuals condition and goals
–
–
–
–
–
Appropriate method
Choice of methods, but surgical for spreading infection
Manage pain
Vascular assessment
Stable heel ulcers
• Maintenance debridement until wound bed is
covered with granulation tissue and devoid of
necrotic.
• Pain management related to debridement
©NPUAP & EPUAP, 2009
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Dressings
•
•
Ulcer should be assessed at every dressing change & the
appropriateness of the current dressing regimen should be
confirmed.
Evidence was summarized for the following dressing types:
– Hydrocolloid (B)
– Transparent film
– Hydrogel (B)
– Alginate (B)
– Foam (B)
– Polymeric membrane dressings (B)
– Impregnated dressings (silver, honey, cadexomer iodine) (B)
– Gauze dressings
– Silicone coated dressings (B)
– Collagen dressings
– Composite dressings
©NPUAP
11th
National
& EPUAP,
NPUAP2009
Biennial Conference • February 27–28, 2009
34
Dressing Highlights
Protection from Friction & Shear
• Consider using dressings to protect body areas at risk for
friction injury or risk of injury from tape.
• Consider placing foam dressings on body areas & PUs at
risk for shear injury.
Reduction of Bioburden
• Consider using silver dressings in infected or heavily
colonized ulcers (B) (Munter, et al, 2006)
– may be toxic to keratinocytes & fibroblasts
– Silver resistant strains of bacteria may be emerging
– Avoid prolonged use; discontinue when infection controlled
•
•
Consider medical grade honey for II & III (Gunes & Esser, 2007)
Consider cadexomer iodine dressings in moderately to
heavily exudating wounds (Moberg, et al., 1983)
©NPUAP & EPUAP, 2009
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Dressings - Highlights
• When other forms of moisture retentive dressings
are not available, continually moist gauze is
preferable to dry gauze.
• Consider silicone dressings to promote
atraumatic dressing changes, especially when
tissue is friable. (Meamue, 2003)
• Consider collagen matrix dressings for non
healing full thickness PrUs.
©NPUAP
11th
National
& EPUAP,
NPUAP2009
Biennial Conference • February 27–28, 2009
36
Assessment & Treatment of
Infection
• Infected ulcers don’t heal!
• Have a high index of suspicion for likelihood of
infection if:
Ulcer has necrotic tissue or foreign body; large and deep;
long duration; frequently contaminated
– Individual has undernutrition, diabetes mellitus, hypoxemia,
poor tissue perfusion, autoimmune disease or
immunosuppression
–
©NPUAP & EPUAP, 2009
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Assessment & Treatment of
Infection
Have a high index of suspicion for local infection in pressure
ulcers when there are no signs of healing for 2 weeks, friable
granulation tissue, foul odor, increased pain in the ulcer,
increased heat in the tissue around the ulcer, increased
drainage from the wound, an ominous change in the nature of
the wound drainage (e.g., new onset of bloody drainage,
purulent drainage), increased necrotic tissue in the wound
bed, pocketing or bridging. (Strength of Evidence = B.)
Cutting KF, Harding KG. Criteria for identifying wound infection. J Wound
Care. 1994;3(4):198-201.
Gardner SE, Frantz RA, Doebbeling BN. The validity of the clinical signs and
symptoms used to identify localized chronic wound infection. Wound Repair
Regen. 2001;9(3):178-86.
©NPUAP & EPUAP, 2009
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How do we assess wound
infection?
©NPUAP & EPUAP, 2009
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Assessment & Treatment of
Infection: Diagnosis
•
•
•
Early diagnosis of spreading acute infection: erythema
beyond ulcer edge, induration, new or increasing pain,
warmth, purulent drainage, crepitus or discoloration of skin,
increasing ulcer size, signs of systemic infection.
Determine bacterial bioburden:
– Quantitative tissue culture (Gold Standard)
– Quantitative swab technique (Levine technique)
Consider the diagnosis of pressure ulcer infection if the
culture results indicate bacterial bioburden of > 105 CFU/g of
tissue and/or the presence of beta hemolytic streptococci.
©NPUAP & EPUAP, 2009
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Assessment & Treatment of
Infection: Management
•
•
•
•
•
Optimize host. Prevent contamination.
Reduce bacterial load with cleansing & debridement. Drain local
abscesses.
Consider the use of topical antiseptics that are properly diluted
and appropriate for pressure ulcers. Antiseptics should be used
for a limited time period to control the bacterial bioburden, to
clean the ulcer and reduce surrounding inflammation. The
professional should be knowledgeable of proper dilutions, as
well as risks of toxicity and adverse reactions.
Consider topical antiseptics for pressure ulcers that are not
expected to heal and are critically colonized.
Consider the use of topical antimicrobial silver or medical-grade
honey dressings for pressure ulcers infected with multiple
organisms because these dressings offer broad antimicrobial
coverage.
©NPUAP & EPUAP, 2009
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Assessment & Treatment of
Infection: Management
•
•
•
Limit the use topical antibiotics on infected pressure ulcers
except in special situations.
Use systemic antibiotics for individuals with clinical evidence of
systemic infection, such as positive blood cultures, cellulitis,
fasciitis, osteomyelitis, systemic inflammatory response
syndrome (SIRS) or sepsis if consistent with the individual’s
goals.
Evaluate the individual for osteomyelitis if exposed bone is
present; the bone feels rough or soft or the ulcer has failed to
heal with prior therapy.
©NPUAP & EPUAP, 2009
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Biophysical Agents
• Consider a course of electrical
stimulation for Stage III & IV and
recalcitrant Stage II pressure ulcers. (A)
• Consider pulsed electromagnetic
treatment for recalcitrant Stage II-IV
PUs.
• Consider NPWT as an early adjuvant for
deep, full thickness PUs. (B)
©NPUAP & EPUAP, 2009
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Biophysical Agents
• Consider infrared therapy for recalcitrant full
thickness ulcers.
• Consider low frequency ultrasound spray for the
treatment of clean recalcitrant full thickness PUs and
low frequency ultrasound for debridement of soft
devitalized tissue.
• Consider a course of hydrotherapy & pulsed lavage.
• There is insufficient peer reviewed, published
evidence to recommend topical oxygen, hyperbaric
oxygen, laser or ultraviolet light therapies for the
treatment of pressure ulcers.
©NPUAP & EPUAP, 2009
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Biological Dressings & Growth
Factors
• Insufficient evidence to support
biological dressings
• PDGF-BB may improve healing
– insufficient evidence to support
recommendations.
– Lacks FDA approval for pressure ulcers
– Approved for diabetic foot ulcers
©NPUAP & EPUAP, 2009
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Surgery for Pressure Ulcers
•
•
•
•
•
Validate end-of-life decisions if anticipating surgery.
Optimize physical & psychological factors that may impair
surgical wound healing.
Assess for osteomyelitis; if present infected bone must be
resected prior to or during surgical closure. (B)
Initiate a program of progressive sitting according to
surgeon’s orders & position the individual on a pressureredistributing chair cushion.
Ensure the individual has a positive social network at home
(B) as well as needed equipment, and the ability to maintain
the equipment and adhere to postoperative needs.
©NPUAP & EPUAP, 2009
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PU Management in Individuals Requiring
Palliative Care
• Dearth of RCTs comparing approaches in human
subjects
• Impossible to eradicate PrU due to multiple risk
factors & co-morbidities
• Healing of PU may be unrealistic goal & new ones
may occur.
• Goals of care to be established in collaboration
with individual & family. To the extent possible,
allow the individual to direct care.
©NPUAP & EPUAP, 2009
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PU Management in Individuals Requiring
Palliative Care – Risk Assessment
• Patient and Risk Assessment
• Pressure Redistribution
• Nutrition and Hydration
• Skin Care
• Pain Assessment and Management
• Pressure Ulcer Care
– Exudate
– Odor
– Pain
©NPUAP & EPUAP, 2009
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“Spin-offs”
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Implementation & Dissemination
©NPUAP & EPUAP, 2009
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The End
©NPUAP & EPUAP, 2009
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