1. Clinical Practice Guideline (CPG) for Pressure Ulcers
For Practitioners

2. 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.
Reported prevalence rates have ranged from 2.3 percent to 28 percent and reported incidence rates from 2.2 percent to 23.9 percent
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. Several contributing or confounding factors are associated with pressure ulcers; however, the significance of these factors has yet to be clarified.1 Pressure ulcers should be distinguished from diabetic, ischemic, and venous ulcers (Table 1), as well as from those caused by trauma and dermatologic disease.
Current published estimates of the prevalence and incidence of pressure ulcers in the long-term care setting are scant

3. What is a Pressure Ulcer?
95% of pressure ulcers develop on the lower body (about 65% in the pelvic area and 30% in the lower extremities)
2-6 times greater mortality risk
Effective pressure ulcer treatment best achieved through interdisciplinary team approach
Almost 95 percent of pressure ulcers develop on the lower body (about 65 percent in the pelvic area and 30 percent in the lower extremities); common sites include the coccyx, heel, ischium, iliac crest, lateral foot, lateral malleolus, sacrum, and trochanter.
A patient with a pressure ulcer has a 2-6 times greater mortality risk than one with intact skin.
Effective pressure ulcer prevention and treatment are best achieved through an interdisciplinary team approach, in which the care team, patient, and family develop an effective plan of care that is consistent with the patient’s prognosis, goals, and expectations.

4. Guidelines for Pressure Ulcers
Recognition
Diagnosis
Prevention and Treatment
Monitoring
AMDA’s guideline for pressure ulcers consists of four major areas:
Recognition: Early recognition of pressure ulcers and of any risk factors associated with the development of pressure ulcers is critical to their successful prevention and management
Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer, and identify related causes and complications.
Prevention and Treatment: The cornerstone of pressure ulcer management is prevention. The purpose of the recognition and assessment phases for patients who have not yet developed a pressure ulcer is to provide the framework for implementation of a prevention strategy Monitoring of patient status and improvement in condition
Monitoring: Ulcer healing may not be achievable in all cases; however, in the absence of complications, some improvement in ulcer characteristics should be expected in most patients. Regular reassessment of ulcer healing should be based on the patient’s overall condition; the number, nature, causes, severity, and complications of existing wounds; and current standards of practice
We’ll discuss the individual steps included in each of the four areas in further detail.

5. Recognition Steps
Examine the patient’s skin thoroughly to identify existing pressure ulcers
Identify risk factors for developing pressure ulcers
Review records/resident interview to identify previous history of pressure ulcers
Patient history of pressure ulcers can be obtained from the medical records, plan of care, transfer summary, other referral data and from the patient’s caregivers.
Staff should be encouraged to perform skin examination as a part of routine care. Caregivers need to be educated to detect signs of breakdown – especially in the early stages.
A history of pressure ulcers is a primary risk factor for the development of new pressure ulcers. Patients with a history of pressure ulcers are more than five times as likely to develop another pressure ulcer as are patients with no such history.
. Need to put in something about the differences here…

6. Distinguishing Features of Common Types of Ulcers
Ulcer Type
Pathophysiology
Location
Diabetic
Peripheral neuropathy secondary to small or large vessel disease in chronic, uncontrolled diabetes
Usually lower extremities
Ischemic
Reduction in blood flow to tissues caused by coronary artery disease, diabetes mellitus, hypertension, hyperlipidemia, peripheral arterial disease, or smoking
Usually distal lower extremities
Tips of toes
Pressure
Unrelieved pressure resulting in damage to skin or underlying tissue
Usually over bony prominences (e.g., buttocks, elbows, heels, ischium, medial and lateral malleolus, sacrum, trochanters)
Venous
Venous hypertension resulting from
incompetence of venous valves, post-phlebitic syndrome, or venous insufficiency. Tend to be irregularly shaped
Usually lower leg region
All staff need to understand the differences between pressure ulcers and vascular ulcers of the lower extremities because they have very different treatment strategies and prognoses

7. F314 Surveyor Guidance: Risk Factors for Developing Pressure Ulcers
According to the surveyor guidance accompanying F314, the risk factors that increase a patient’s susceptibility to developing pressure ulcers, or that may impair the healing of an existing pressure ulcer, include but are not limited to the following:
Comorbid conditions (e.g., diabetes mellitus, end-stage renal disease, thyroid disease)
Drugs that may affect ulcer healing (e.g., steroids)
Exposure of skin to urinary or fecal incontinence
History of a healed Stage III or IV pressure ulcer
Impaired diffuse or localized blood flow (e.g., generalized atherosclerosis, lower-extremity arterial insufficiency)
CMS’s interpretive guidance for 42 CFR (F314) identifies risk factors and comorbid conditions that may increase the risk of the development of pressure ulcers. Conditions related to these risk factors should be evaluated and the findings documented in the patient’s medical record.

8. F314 Surveyor Guidance: Risk Factors for Developing Pressure Ulcers
Impaired or decreased mobility and functional ability
Increase in friction or shear
Moderate to severe cognitive impairment
Resident refusal of some aspects of care and treatment
Undernutrition, malnutrition, and hydration deficits
(Adapted from CMS, 2007)

9. Assessment
Assess the patient’s overall physical and psychosocial health and characterize the pressure ulcer
Identify factors that can affect ulcer treatment and healing
Identify priorities in managing the ulcer and the patient

10. Assessment
A pressure ulcer should be assessed in the context of the patient’s overall clinical, functional, and cognitive status.
Assess the status of each of the patient’s current medical conditions.
Assess the patient’s nutritional status, including dietary and fluid intake
Assess for the presence of medical conditions that may interfere with independent feeding or decrease overall oral intake
In most cases, weekly reassessment and documentation of ulcer characteristics is recommended. More frequent reassessment may be necessary for ulcers that are not responding to treatment or are worsening despite treatment. Consider photographing the ulcer as part of the assessment

11. Assessment
In patients with lower-extremity ulcers, assess for the presence of coolness, delayed capillary refill, dusky discoloration, or pedal pulses. The ankle-brachial index, determined by Doppler arterial studies, may be helpful in determining whether a lower-extremity ulcer is caused by vascular insufficiency or by pressure.
Assess the patient’s bed and chair mobility and ability to sense and react to pain and discomfort.

12. Other Factors That Should Be Assessed in a Patient With a Pressure Ulcer
Comorbid conditions (e.g., anemia, congestive heart failure, diabetes, edema*, immune deficiency, malignancies, peripheral vascular disease, thyroid disease)
Complications (e.g., cellulitis, osteomyelitis)
Pain
Presence of:
Contractures
Dementia
Depression
Terminal illness

13. Staging of pressure ulcers
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.
Stage I
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).
The physical examination should include identification of suspected deep tissue injury and staging of the ulcer or ulcers (see Table 4). If the ulcer is covered by eschar, however, the depth of damage to the underlying tissues may not be initially evident and the ulcer cannot be accurately staged. The MDS 2.0 requires that an ulcer with necrotic eschar be categorized as a Stage IV until the eschar has been debrided to allow staging.
The coding of deep tissue injury on the MDS 2.0 is controversial because the MDS does not recognize this wound classification. Because the skin is intact, a deep tissue injury meets the MDS definition of a Stage I ulcer. A deep tissue injury wound may rapidly deteriorate to full-thickness skin loss If it is coded as a Stage I ulcer, it may appear on quality improvement reports that the wound has worsened. In this circumstance, the characteristics of the wound should be carefully documented in the progress notes.

14. Staging of pressure ulcers
Stage II
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink ulcer bed, without slough*. May also present as an intact or open/ruptured serum-filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration* or excoriation. Bruising indicates suspected deep tissue injury

15. Staging of pressure ulcers
Stage III
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining* and tunneling*. Further description: The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

16. Staging of pressure ulcers
Stage IV
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the ulcer bed. Often include undermining and tunneling. Further description: The depth of a Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

17. Staging of pressure ulcers
Unstageable
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the ulcer bed. Further description: Until enough slough and/or eschar is removed to expose the base of the ulcer, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema* or fluctuance*) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.
National Pressure Ulcer Advisory Panel, 2007

18. Factors that can affect ulcer treatment and healing
Physiologic factors
Functional factors
Psychosocial factors
Ethical considerations
Physiologic factors: Previous skin breakdown at the same site or other skin-integrity problems (e.g., dermatitis);
Presence and severity of significant comorbidities (e.g., diabetes, fecal incontinence);
Presence of malnutrition or cachexia due to underlying disease;
Presence of contractures; and
Use of medications (e.g., corticosteroids) that influence the immune system, host defenses, and skin characteristics
Functional factors, including impaired mobility, a self-care deficit, and incontinence (especially fecal incontinence
Psychosocial factors. The patient's ability and willingness to adhere to the treatment program will influence pressure ulcer management. Some patients (e.g. those who have behavioral disturbances associated with dementia, delirium, or psychosis
Ethical considerations. Review any advance directives or other care instructions (e.g., living will) that may limit the scope of ulcer-related or adjunctive treatments

19. Identify Priorities in managing the ulcer and the patient
Effective management of a pressure ulcer requires:
Identification and treatment of causative factors when feasible,
Identification and treatment of modifiable comorbid conditions,
Provision of optimal nutritional support,
Determination of the best topical care to facilitate ulcer healing,
Prevention and management of infection* of the ulcer or adjacent tissue, and
Pain control related to the ulcer and any comorbid conditions.
Depending on findings and interpretations up to this point, certain steps may have a higher priority than others (e.g., addressing predisposing or related systemic factors, managing infection, removing necrotic tissue, preventing additional skin breakdown, and addressing psychosocial factors that influence treatment selection). If the care team identifies multiple priorities, it is important to address systemic, life-threatening complications first and other issues as soon as possible.

20. Prevention and Treatment
Pressure Ulcer Prevention Measures
Create a turning and positioning schedule that is based on the patient’s individual risk factors
Do not massage reddened areas over bony prominences
Evaluate and manage urinary and fecal incontinence
Initiate a plan to prevent or manage a contracture
Inspect skin during bathing or daily personal care
Maintain adequate nutrition and hydration if possible
Maintain the lowest possible head elevation to reduce the impact of shear
Position the patient to minimize pressure over bony prominences and shearing forces over the heels and elbows, base of head, and ears
Use appropriate offloading or pressure-redistribution devices
Use lifting devices such as draw sheets or a trapeze
Use proper transferring techniques
The cornerstone of pressure ulcer management is prevention. The purpose of the recognition and assessment phases for patients who have not yet developed a pressure ulcer is to provide the framework for implementation of a prevention strategy that reduces the risk of pressure ulcer occurrence.

21. Unavoidable Pressure Ulcers
Under the surveyor guidance accompanying F314, an unavoidable pressure ulcer is a pressure ulcer that develops even though a facility has done the following:
Evaluated the patient’s clinical condition and risk factors;
Defined and implemented interventions consistent with patient needs, goals, and recognized standards of practice;
Monitored and evaluated the impact of these interventions; and
Revised the approaches as appropriate

22. Unavoidable Pressure Ulcers
The following clinical circumstances, among others, may impede or prevent healing or result in additional ulcer development that may be unavoidable:
Cachexia,
Metastatic cancer,
Multiple organ failure,
Sarcopenia,
Severe vascular compromise, and
Terminal illness.

23. Nutrition
Increased protein intake is often emphasized in patients with nonhealing wounds; adequate intake of any single nutrient, however, does not prevent pressure ulcer formation or facilitate healing.
Many clinicians recommend caloric intake of 30 kcal/kg to 35 kcal/kg33 and daily protein intake of 1.2 to 1.5 g/kg of body weight34 for nutritionally compromised patients who have or are at risk of pressure ulcers

24. Pain Management
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

25. Turning and Positioning
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

26. Manage Pressure
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.

27. Necrotic Tissue
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.

28. Debridement of an ulcer
When choosing a debridement method, consider
Ulcer size,
Amount of slough and exudate,
Presence and severity of pain associated either with the ulcer or with the method of debridement,
Feasibility of performing sharp or surgical debridement, and
Risks of transporting the patient outside of the facility vs. the benefits of surgical debridement.

29. Heel Ulcers
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.

30. Cleaning the wound An effective antiseptic should: Act quickly;
Be nonirritating;
Be nontoxic to viable tissue;
Have a broad spectrum of activity;
Have low resistance potential; and
Work in the presence of blood, fibrin, pus, and slough

31. Ulcer Dressings The goals of dressing an ulcer are to:
Keep the ulcer bed moist and the surrounding skin dry,
Protect the ulcer from contamination, and
Promote healing.

32. Factors to Consider When Selecting Ulcer Care Products
Burden to patient (i.e., number of daily dressing changes required)
Cost-effectiveness of product
Costs of ancillary supplies and equipment associated with treatment
Ease of use and cost of staff time to use the product
Safety, efficacy, and likelihood and potential severity of complications
Ulcer characteristics (e.g., depth, condition of surrounding skin, location near sources of contamination, presence and amount of exudate)

33. F314 Surveyor Guidance: Monitoring Considerations
Daily Monitoring
Evaluate ulcer if no dressing is present
Evaluate status of dressing if present: Is dressing intact? Is drainage present? If so, is it leaking?
Status of area surrounding ulcer that can be observed without removing the dressing
Presence of possible complications (e.g., signs of increasing area of ulceration, soft tissue infection)
Evaluate whether pain, if present, is adequately controlled
Document when a change or complication is identified

34. F314 Surveyor Guidance: Monitoring Considerations
Weekly or Dressing Change Monitoring
Location and staging of ulcer
Size (perpendicular measurement of greatest extent of length and width of ulceration); depth; and presence, location, and extent of undermining, tunneling, or sinus tract*
Presence of exudate; if present, type (e.g., purulent, serous), color, odor, approximate amount
Presence of pain; if present, nature and frequency (e.g., episodic, continuous)
Status of wound bed: color and type of tissue; evidence of healing (e.g., granulation tissue); necrosis (slough, eschar)
Description of wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration)

35. F314 Surveyor Guidance: Monitoring Considerations
Use of Photography in Pressure Ulcer Monitoring
Photography may be used in monitoring as part of the facility’s compliance efforts, if the facility has developed a protocol consistent with accepted standards, which include the following:
Frequency of use
Photos taken at a consistent distance from the wound
Type of photographic equipment used
Means to ensure that digital images are accurate and not modified
Inclusion of resident identification, ulcer location, dates, etc., within the photographic image
Parameters for comparison over time

36. IMPORTANT!
It is important to establish goals consistent with the values and lifestyle of the individual and his/her family.