Standardized Order Sets and Protocols: Complicated Pressure Ulcers

Order Sets

Standardized Order Sets vary for Physicians and for Nursing. Integration of the order sets through electronic physician order entry and retrieval require that the process be aligned and that the order sets result in proper tasking of nurses to assure that orders are properly assigned and completed. It is suggested that the order sets be coordinated and that some portions be automatically generated to maximize the impact for pressure ulcer prevention.

Standardized Order sets for Pressure Ulcer Prevention and for Pressure Ulcer Treatment differ but should be integrated. This is a medically intuitive location for the order sets. Treatment protocols for Stages I through IVcan be developed and protocol driven using standardized order sets which are convenient and which lead to congruency of treatment protocols. While product driven protocols may be necessary to a point, process protocols are encouraged.

Surgical debridement prior to dressing changes is most appropriate for some Stage II and for Stage III ulcers.  Stage IV ulcers benefit from surgical debridement of the wound edges, osteotomy to debride effected bone and the application of a VAC© dressing.  If infected, empiric IV antibiotics and an Infectious Disease consult may be warranted. Plastic surgery may be consulted for Stage III and IV ulcers. Definitive surgical intervention with primary closure is a possibility in a select group of patients, although the rates of flap breakdown and need for further surgeries remains high.  Order sets for these treatments are more difficult to create, but standardization of Vac orders eliminates potential for incorrect Vac settings and miscommunication. It may also assist with the completion of paperwork necessary for discharge planning.

Intensive care and high acuity unit interventions may require additional interventions. These may include: Positioning wedges, Occupational Therapy Consultation for positioning, Bedside books for education and documentation, Pressure Ulcer log books. 

Suggestions for Nursing Order Sets:

General and Preventative Orders

• Braden scale for prediction pressure ulcer risk score-can be made a form

  ->16 no risk
  -15-16 at risk
  -13-14 at moderate risk
  -12 or less at high risk
  

• Nursing assessments of skin q shift on anyone with a risk and q24 hours with people not at risk
• Routine skin care order set for prevention for people at risk.

  -air mattress
  -off loading boots to protect heels
  -barrier creams if incontinent
  -turn and reposition q2 hours order
  -skin safety plan to minimize friction and shear factors, manage pressure, manage moisture and maintain adequate hydration and nutrition

Skin safety plan

Suggested Nursing Orders to minimize friction and shear

• Use transfer and assistive devices
• Use lifts to assist in transfers and repositioning
• Maintain head of bed at or below 30 degrees when repositioning and match knee angle with head of bed to decrease sliding
• Keep skin clean and dry
• Use a trapeze if not contraindicated so patient can assist in repositioning.
• Lift the body off the bed/chair when repositioning instead of dragging the patient against the bed/chair when repositioning
• Avoid elevating head of bed more than 30 degrees unless contraindicated. Sit at 90 degree angle when in chair decreases shear/friction.
• Pad between skin surfaces that may rub together
• Use of heel and elbow pads to reduce friction
• Keep skin well hydrated and moisturized
• Use lubricated or powdered bedpans and roll patients onto the bedpan instead of pushing it under and pulling it out.
• Protect skin from moisture. Q1-2 hour incontinence checks on patients.

Manage Pressure

• Frequent repositioning-minimum q2 hrs
• Use pillows or wedges to redistribution pressure on bony prominences
• Pressure reducing mattress overlay for low risk, alternating pressure mattress/overlay for moderate risk, specialty bed for high risk that is low air loss and alternating pressure.
• When sitting encourage patient to weight shift every 15 minutes if able, if not reposition in chair q1 hour.
• Utilize chair cushions for pressure redistribution for low risk, gel cushions for moderate risk, alternating pressure cushions for high risk.
• If patient is over 300lbs, consider bariatric bed and appropriate sized support surfaces (bariatric bedside commodes, wheelchairs, chairs, etc)
• Free float heels by elevating calves on pillows
• Check all medical devices for potential pressure such as Foley catheters, IV tubing, restraints, oxygen tubing
• Limit the number of layers between support surface and patient
• Ambulate patients when possible

Manage Moisture

• Toileting schedule-q1-2 hours
• Bowel/bladder programs
• Cleanse skin and apply moisture barriers for incontinent episodes
• Contain wound drainage
• Prevent moisture accumulation in skin folds
• Select absorbent under-pads and briefs to wick away moisture from skin

Maintain adequate nutrition/hydration

• Provide nutrition compatible with individual wishes or conditions (FYI IV fluids and tube feedings can increase chance for incontinence and diarrhea)
• Nutrition consult as needed
• Advance diet as tolerated and add protein and vitamin supplements as indicated-can make this a check off box for them to click which ones they would order the most.

Treatment Orders

Wound Assessment

• Review History and Physical
• Review etiology of wound
• Assess psychosocial needs
• Assess nutritional status
• Assess wound care: dressing changes and when initially identified

Chart wound assessment-this could be made into a form for physicians if a wound is found on admission. It could be then filled out by the nursing staff if found after admission.

• A-Anatomical location
• S-Size and Shape
• S-Stage
• E-Exudate
• S-Surrounding skin condition
• S-Sinus tract/tunneling
• M-Margins
• E-Edges
• N-Nose (odor)
• T-Tissue of wound base.

Suggestions for Physician Order Sets

• Integrate all Treatment Order Sets with Prevention Order Sets
• Recommend Enterostomal therapy consult for pressure ulcer any stage.
• Order Sets should emphasize nutritional support and optimization of control of underlying condition

Stage I pressure ulcer

Dressing change orders:

• Film dressing daily after cleansing and drying
• Hydrocolloid dressing daily after cleansing and drying. May vary depending upon the product which is chosen
• Hydrogel sheet q3 days after cleansing and drying

Stage II pressure ulcer

Include the orders for stage I
Dressing change orders:

• Alginate daily or q 48 hours after cleansing and drying
• Foam dressing q3 days after cleansing and drying

Stage III and IV pressure ulcers

Dressing change orders:

• Alginate daily or q 48 hours after cleansing and drying
• Foam dressing q3 days after cleansing and drying
• Polymer gell sheet q3 days after cleansing and drying
• Debridement agents

Ointment 1 application daily and cover with dry gauze after cleansing and drying
Topical spray 1 application topically daily after cleansing and drying. Cover loosely with gauze.

Treatment options should include:

• Goal of treatment (healing, maintenance, palliation)
• Cleanse wound-prior to assessment, before dressing application, and choosing appropriate solution for cleansing with indication of frequency
• Consider adjunct therapy
• Debride the wound if necessary (sharp, chemical, mechanical, autolytic)
• Consult wound care or surgeons
• Pain management prior to dressing changes or debridement
• Wound cultures
• Surgical Indications
• Radiological Imaging to determine extent of wound especially in tunneling wounds or those suspected to have underlying osteomyelitis

Online source:
http://www.icsi.org/pressure_ulcer_treatment_protocol__review_and_comment_/pressure_ulcer_treatment__protocol__.html Accessed July 31, 2009.

Download Examples of Standardized Order Sets from Penn State Hershey, Hershey, PA provided by Barbara Hoffmann, MD.