Prevent

AHS’ Formulary is currently evaluating several tools to be included in the prevention recommendations associated with AHS’ Formulary Guidelines. We are also in the process of developing a full set of recommendations for prevention by etiology that will align current guidelines, standards and best practices with the treatment recommendations in AHS’ Treatment and Documentation protocols.

AHS always recommends that practitioners follow appropriate facility guidelines for wound prevention as well as all applicable state and federal laws and regulations. Please note that prevention recommendations below are abridged. Complete content is available in AHS’ Wound Treatment Guidelines.

Selected Pressure Ulcer Prevention Recommendations

Pressure ulcers develop when we do not aggressively, quickly and definitively alleviate areas of excess pressure when caring for high risk patients with intact skin, or patients with pressure ulcers already developing. And unless the root cause (excess pressure or shear) is properly dealt with, all the other interventions will be ineffective.

The key to preventing and treating pressure ulcers is to reduce pressure, and the basic standard for reducing pressure is repositioning. Traditionally, caregivers will reposition or offload the immobile patient every two hours. In so doing, they relieve the occluding pressure in capillaries and allow reperfusion of the area. However, this standard approach must be individualized for each resident and the specific support surface they are using. Tissue tolerance testing can be used to individualize a patient’s repositioning schedule.

In Minnesota, the tissue tolerance test is used to identify those patients at risk for developing a stage 1 ulcer. In the test, the resident is allowed to sit or lie on a support surface (Wheel Chair cushion or bed) for two hours. If redness occurs at the location of the pressure and persists for more than 45 minutes, the resident did not tolerate that position, on that surface. This same resident should then be tested at a shorter time interval (1.5 hours) to determine the acceptability of the shorter interval for turning or repositioning. The testing process continues by reducing the time increments by one half hour with each test until the caregiver establishes a time interval at which the patient does not experience redness for more than 45 minutes at the site of the pressure.

In conjunction with fundamental turning and repositioning programs, specific tools are frequently used to aid with the prevention of pressure ulcers. These tools are known as pressure reduction or pressure relief surfaces.

Selected Arterial Wound Prevention Recommendations

Medical management of arterial insufficiency is of primary concern in order to facilitate wound healing for wounds created or exacerbated due to arterial insufficiency.

Is the patient a candidate for vascular intervention (angiography, PTA [percutaneous transluminal angioplasty], or surgical intervention)?

Methods for management of arterial insufficiency include:

• Anticoagulants (aspirin, Plavix™, Heparin, Coumadin™)
• Control of hypertension, diabetes, and lipid disorders
• Smoking cessation
• Lower extremity physical therapy and / or walking programs as tolerable

Selected Venous Ulcer Prevention Recommendations

Elimination of Edema is the primary requirement for improving venous wounds. First consider medical contributors to edema, assessing requirements for treatment of congestive heart failure, hypothyroidism, malnutrition and pulmonary disease. A stepwise approach to control of edema using appropriate external control measures should also be undertaken after accounting for the underlying causes and severity of the condition.

Selected Diabetic Wound Prevention Recommendations

Diabetes is a complex medical condition predisposing people to foot ulcers in three ways.

• Peripheral neuropathy impairs normal protective mechanisms by reduction or elimination of pain sensation from minor traumas.
• Impaired circulation due to large vessel atherosclerosis and microcirculatory (capillary) abnormalities limits oxygen, nutrients and immune responses.
• In addition, poor glycemic control impairs immune response and regeneration of healthy new tissue.

Effective intervention and prevention of diabetic foot wounds requires a coordinated, multidisciplinary care approach. This is likely to include primary care practitioners, and may also include other external resources such as surgical specialists with expertise in diabetic ulcer management, endocrinologists, podiatrists, orthotists and other specialists as necessary.