Pressure Ulcer

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Contents 1 More Specific Terms 2 Introduction 3 Classification 4 Etiology 5 Epidemiology 6 Pathology 7 Laboratory 8 Complications 9 Differential-diagnosis 10 Management 11 More General Terms 12 Additional Terms 13 References

More Specific Terms

• diabetic foot ulcer; diabetic foot lesion; diabetic lower extremity lesion

Introduction

• Any lesion caused by unrelieved pressure resulting in damage of underlying tissue.

Classification

• see staging of pressure ulcers

Etiology

• extrinsic factors

• pressure
• shear forces
• moisture
• chemical irritants

• host (intrinsic) risk factors:

• debilitating systemic disease
• immobility & inactivity, flaccid paralysis

• spinal cord injury & neurologi disease

• incontinence, urinary incontinence & fecal incontinence
• malnutrition, low serum albumin < 3.0 g/ dL

• morbid obesity

• febrile illnesses, infections
• altered mental status
• diminished sensation
• fracture
• hypotension
• hypovolemia
• anemia
• increased metabolic demands
• advanced age
• immunosuppression [9]

Epidemiology

• acute care hospital

• all patients 3-11%
• bed-bound patients 28% (for 1 week)
• ICU patients: 22-29/1000 patient days
• likelihood of pressure sores inversely correlated with frequency of repositioning

• nursing home residents

• 11-56% of new nursing home residents
• mortality for nursing home patient with pressure ulcer is 2-6 times that for patients without
• prevalence higher in blacks than whites [11]

• heels & sacrum are most common sites for pressure ulcers

Pathology

• pressure

• capillary filling pressure is about 32 mm Hg*
• when pressure between support surface & bony prominence is > 32 mm Hg, blood flow stops
• ischemia, acidosis, toxin accumulation, hemorrhage into interstitium & cell death occur
• eventually intrinsic fibrinolysis diminishes & intra- vascular coagulation further compromises perfusion even after pressure is relieved
• pressure is more easily distributed in superficial tissue thus deeper tissues may be more vulnerable
• tissue damage apparent 1-2 hr of 60 mm Hg; pressure > 70 mm Hg for 2 hr causes irreversible tissue damage
• average sacral pressure on standard hospital mattress is 150 mm Hg
• highest pressure over ischial tuberosity in chair-bound person (150-500 mm Hg) [8]

• friction

• removal of stratum corneum & damage to underlying layers
• can occur with moving patients against bedding (use drawsheet)

• shear

• friction hold skin in place, but gravity pulls axial skeleton down
• results in stretching of perforating arterioles & compromise of dermal perfusion

• moisture

• causes softening of stratum corneum with exacerbates effects of friction

• * 32 mm Hg measured from human cuticular capillaries different tissues may tolerate different pressures pressure > 70 mm Hg for 2 hr causes irreversible tissue damage

Laboratory

• culture

• avoid culturing wound unless you plan to treat (all pressure ulcers are colonized with bacteria)
• swab technique more practical than tissue biopsy
• needle aspiration

Complications

• osteomyelitis

Differential-diagnosis

• arterial ulcer (management is very different)

Management

• general measures

• avoid pressure on bony prominences

• ischial tuberosity ( wheel chair)
• greater trochanter (30 degree angle from supine)
• heels ( supine); use soft booties

• reposition every 2 hours ( every hour for chair-bound* individuals)

• special support surfaces may allow for repositioning less frequently than every 2 hours [8]
• repositioning every 4 hours has not been shown to reduce pressure ulcers [8]

• adequate nutrition

• dietary protein 1.5-2.0 g/kg/day [8]
• evidence for dietary intervention in healthy elderly (not- malnourished) is lacking [8]

• control moisture: incontinence management, barrier creams
• use drawsheet when moving patients to avoid friction
• pressure relief

• low air loss mattress
• air-fluidized beds
• no evidence for benefit of sheepskin or egg crate mattress
• specialized foam mattress overlays on operating tables
• do NOT use doughnuts

• mild cleansers ( normal saline)
• moisturizing agents
• remove excess skin secretions, excretions

• early mobilization
• in-service programs

• stage I (see staging of pressure ulcers)

• cleanse with non-drying soap & water
• no dressing indicated

• stage II

• goals

• moist wound bed & dry surrounding skin
• minimize pain

• cleanse with normal saline
• dressing

• polyurethane foam
• foam wafers
• hydrogel wafers (Restore)
• hydrocolloid wafers (Restore)

• stages III & IV without necrosis

• goals

• moist wound bed & dry surrounding skin
• minimize pain

• normal saline irrigation
• dressing

• if very shallow, use polyurethane foam, foam wafers, hydrogel wafers, or hydrocolloid wafers
• if dead space

• lightly fill with saline-moistened gauze, kept continuously moist
• remoisten gauze before removal if dried & adhered to tissue

• topical phenytoin may enhance wound healing
• surgical excision & primary closure may be option [7]

• patients with deep wounds, without infection
• good nutritional status
• able to comply with frequent repositioning

• stage III & IV with necrosis &/or excessive exudate

• goals

• debridement of necrotic tissue
• minimize damage to granulating tissue
• keep surrounding skin intact & dry

• debridement

• advancing cellulitis, bacteremia or sepsis

• prompt sharp debridement

• eschar: soften with an occlusive dressing, then sharp debridement
• slough

• enzymatic or autolytic debridement
• may be combined with whirlpool

• saline irrigation 4-15 PSI

• 250 mL squeeze bottle
• Water Pik ( dental irrigatory) at lowest setting
• 35 mL syring with 19 gauge angiocatheter

• dressing

• wet to dry dressing; loosely fill dead space; do NOT moisten before removal
• after sharp debridement with bleeding, dry dressing for the 1st 8-24 hours; moisten before removal
• if excessive exudate

• alginate or other highly absorptive dressing
• alternatively, more frequent dressing changes
• protect surrounding skin with moisture barrier ointment

• if malodorous or purulent exudate

• topical antimicrobial agents
• if cellulitis, treat with systemic antibiotics

• once necrosis is no longer present, stop debridement & use continuously moist saline dressing

• pressure ulcer assessment

• use pressure sore status tool to assess at baseline, then at regular intervals to assess healing
  

• * weight shift every 15 minutes for chair-bound patients written plan with participation of occupational therapy [8]

More General Terms

• cutaneous ulcer

Additional Terms

• pressure ulcer assessment
• pressure ulcer risk scale
• staging of pressure ulcers

References

1. nlmpubs.nlm.nih.gov/hstat/ahcpr/
2. Goode & Thomas, Clinics in Geriatric Medicine 13(3):543, 1997
3. Cervo & etal, Geriatrics 55:55, 2000
4. Klitsman et al, Clinics in Plastic Surgery 25:443, 1998
5. Patterson & Bennett JAGS 43:919, 1995
6. Roof L, UCLA Dept. of Nursing Clinical Standard, ref # 11, 1997
7. Bates-Jensen BM. In: UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
8. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004; 7th edition 2010
9. Medical Knowledge Self Assessment Program (MKSAP) 15, American College of Physicians, Philadelphia 2009
10. Management and Treatment of Pressure Ulcers includes recommendations from AMDA, CSCM, Singapore MOH, RNAO, UIGN, and WOCN. [1]
    - Pressure Ulcer Prevention includes recommendations from JHF, NCCNSC/NICE, RNAO, UIGN, and WOCN [2]
11. Li Y et al. Association of race and sites of care with pressure ulcers in high-risk nursing home residents. JAMA 2011 Jul 13; 306:179 PMID: [3]
12. National Guideline Clearinghouse
    - The use of pressure-relieving devices (beds, mattresses and overlays) for the prevention of pressure ulcers in primary and secondary care. ngc-guideline: [4]
    - Assessment and management of stage I to IV pressure ulcers. Registered Nurses Association of Ontario ngc-guideline: [5]
    - Preventing pressure ulcers and skin tears. In: Evidence-based geriatric nursing protocols for best practice. Hartford Institute for Geriatric Nursing ngc-guideline: [6]
    - Guideline for prevention and management of pressure ulcers. Wound, Ostomy, and Continence Nurses Society (WOCN) ngc-guideline: [7]
    - Pressure ulcers in the long-term care setting. American Medical Directors Association ngc-guideline: [8]
    - Pressure ulcer prevention and treatment. Health care protocol. Institute for Clinical Systems Improvement ngc-guideline: [9]
    - Pressure ulcer prevention recommendations. In: Prevention and treatment of pressure ulcers: clinical practice guideline. National Pressure Ulcer Advisory Panel ngc-guideline: [10]
    - Pressure ulcer treatment recommendations. In: Prevention and treatment of pressure ulcers: clinical practice guideline. National Pressure Ulcer Advisory Panel ngc-guideline: [11]
    - Association for the Advancement of Wound Care guideline of pressure ulcer guidelines. ngc-guideline: [12]
    - Evidence based practice guidelines for the nutritional management of adults with pressure injuries. Trans Tasman Dietetic Wound Care Group ngc-guideline: [13]
    - (1) Risk assessment & prevention of pressure ulcers. (2) Risk assessment & prevention of pressure ulcers 2011 supplement. Registered Nurses' Association of Ontario (RNAO) ngc-guideline: [14] .Guideline synthesis
    - Management and Treatment of Pressure Ulcers, includes recommendations from AMDA, CSCM, Singapore MOH, RNAO, UIGN, and WOCN [15] [16]
    - Management of Pressure Ulcers Registered Nurses' Association of Ontario (RNAO) Wound, Ostomy, and Continence Nurses Society (WOCN) [17]
    - Pressure Ulcer Prevention , includes recommendations from JHF, NCCNSC/NICE, RNAO, HIGN, and WOCN. Hartford Institute for Geriatric Nursing (HIGN) Registered Nurses Association of Ontario (RNAO) [18] [19]
    - Prevention of Pressure Ulcers Registered Nurses' Association of Ontario (RNAO) Wound, Ostomy, and Continence Nurses Society (WOCN) [20]

pressure ulcer (decubitus ulcer, bedsore)