Ashkan Javaheri, MD, Stanford University School of Medicine
Daniel Bluestein, MD, Eastern Virginia Medical School
TIPS FOR DEALING WITH PRESSURE ULCERS
A pressure ulcer is a localized injury that results from unrelieved pressure to the skin and underlying tissue. These ulcers usually occur over bony prominences such as the sacrum, ischial tuberosities, greater trochanters, heels and lateral malleoli. About 70% of pressure ulcers occur in people over age 65, and they are seen in 9-22% of nursing home residents and 5-32% of patients in hospitals.
The prognosis for successful treatment once pressure ulcers have formed is guarded at best. Although more than 70% of stage II ulcers heal after six months of appropriate treatment, only 50% of stage III ulcers and 30% of stage IV ulcers heal within this period. Management, therefore, should focus on prevention as well as treatment.
Both extrinsic and intrinsic risk factors exist for pressure ulcer formation. Extrinsic risk factors include constant pressure from immobility, shear forces related to sliding, and the presence of moisture on the skin. Intrinsic risk factors include decreased sensory perception and malnutrition. The Braden Scale is a frequently used, helpful adjunct for assessing risk in bedbound patients.
Preventive measures include pressure reduction via repositioning, avoidance of shear forces, and use of static pressure-reducing devices. The latter include foam, water, gel, and air mattresses or mattress overlays, foam wedges, and pads for joints and heels. Dynamic devices (e.g., alternating pressure mattresses) may be needed if a patient cannot reposition independently. Despite best efforts, however, some pressure ulcers are unavoidable.
|Table 1. Characteristics of Pressure Ulcers, by Stage|
|Stage I||Intact skin with non-blanchable redness|
|Stage II||Partial-thickness loss of dermis; no fat visible|
|Stage III||Full thickness loss, fat may be visible|
|Stage IV||Full thickness loss with exposed bone, tendon, or muscle|
|Unstageable*||Base is covered with slough or eschar. Debridement required to stage.|
Once an ulcer is present, it should be assessed for location, size (length, width, depth), drainage, necrotic and granulation tissue, tunneling and undermining, wound margins, cellulitis, and most importantly, staging (Table 1). Remember, pressure ulcers do not "progress through" stages and back-staging should be avoided. The Pressure Ulcer Status for Healing (PUSH) tool can help monitor progress.
|Table 2. Debridement Methods|
|Sharp||Scalpel or scissors||Fastest method. Indicated when infection is present|
|Saline-moistened wet-to-dry gauze can be used for debridement, but not for routine dressing changes|
|Autolytics||Dressings||Some dressings are autolytic. See Table 3.|
Treatment of pressure ulcers is interdisciplinary and includes reducing or relieving pressure, wound cleansing, debriding necrotic tissue, using appropriate dressings and antibiotics, and ensuring good nutrition.
Relieving Pressure and preventing further ulcers is achieved with the techniques already discussed. Dynamic pressure-reducing devices are recommended for patients who cannot reposition independently, for those with multiple large ulcers or non-healing ulcers, and after flap surgeries.
Wound Cleansing should be performed, both initially and with each dressing change - preferably with saline or commercial wound cleanser. Antiseptics (e.g., Betadine) should be avoided.
Debridement of necrotic tissue until granulation tissue is visible is essential, with the exception of heel ulcers with a stable, dry eschar. Table 2 lists debridement methods.
Dressings that maintain a moist wound environment facilitate healing and can be used for autolytic debridement. Dressing selection is dictated by clinical judgment and wound characteristics (Table 3). No moist dressing has been shown superior to any other.
Topical antibiotics, such as silver sulfadiazine cream, should be used for up to two weeks on clean ulcers that are not healing properly, after two to four weeks of optimal wound care. Quantitative bacterial tissue cultures (needle aspiration or ulcer biopsy preferred) should be performed for non-healing ulcers after a trial of topical antibiotics or if there are overt signs of infection. Systemic antibiotics are not recommended unless there is evidence of advancing cellulitis, osteomyelitis, or bacteremia.
Nutrition is essential and starts with good oral intake. If PO intake becomes inadequate or impractical, enteral or parenteral feeding should be considered. The goal is to achieve positive nitrogen balance (approximately 30 to 35 calories/kg/day and 1.25-1.5 g of protein/kg/day). Protein, vitamin C, and zinc supplements can also be considered, although supporting data have been inconsistent thus far.
Other Approaches Growth factors (e.g., platelet-derived growth factor becaplermin (Regranex®)) and vacuum-assisted closure for recalcitrant stage III-IV ulcers are emerging management options. The roles of electromagnetic therapy, ultrasound, and hyperbaric oxygen therapy are unclear.
|Table 3. Summary of Dressings for Pressure Ulcers|
|Transparent film||Stages I-II||Retains moisture, facilitates autolytic debridement; not for infected wounds or fragile skin|
|Foam||Stages II-IV||Mostly nonadherent; absorbs light and heavy exudates; recommended for fragile skin|
|Hydrocolloid||Stages I-IV||Not for heavy exudate; molds easily|
|Hydrogel||Stages II-IV||Relieves pain; good for deep wounds (fills dead space) & infected wounds; not for dry eschar|
|Alginate||Stages II-IV||Absorbs moderate to heavy exudate; good for deep wounds (fills dead space) and infected wounds; not for dry eschar|
References and Resources
- Bluestein D, Javaheri A. Pressure ulcers: prevention, evaluation, and management. Am Fam Physician. 2008;78(10):1186-94.
- Bergstrom N, United States. Treatment of Pressure Ulcers Guideline Panel. Treatment of pressure ulcers. Rockville, Md: U.S. Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1994.
- National Pressure Ulcer Advisory Panel (NPUAP). Updated staging system (2016).