RISK FACTORS: Immobility (e.g., quadriplegia), Spinal cord injuries, Malnutrition and low body weight, Hypoalbuminemia (< 3.5 g/dL), Previous pressure ulcer, Extended time in hospital or nursing home
APPROPRIATE HEALTH CARE
• An interdisciplinary approach usually indicated in nursing home, inpatient or home care settings if trained
supervision available
• Wound healing from infl ammation to remodeling is dependent on energy and protein synthesis
• Complications will require inpatient setting to treat systemic infection, extensive debridement or skin grafting
GENERAL MEASURES
. Improve overall nutritional status (adequate protein intake)
. Clean wound each time dressing is changed to remove dead tissue, excess fl uid and other debris
. Avoid rolling the patient, and prop heels off bed
. Insuffi cient evidence whether sterile technique is better than clean dressing change in reducing infection risk or improving healing time.
. Healing enhanced with body temperature maintained at 37 C (97.7 F) and an acidic pH
. Never use antiseptics and skin cleansers (eg, Betadine) which harm the tissue
. Surgery for wounds not responding to treatment within 2-4 weeks
. Debridement of necrotic pressure ulcers using occlusive dressings, hydrotherapy, proteolytic enzymes, or surgical or laser debridement
. Pressure reduction products such as specialized beds and repositioning every two hours to relieve pressure
at site of ulceration (air-fl uidized or low-air-loss beds); static-pressure and foam mattresses, water mattresses,
sheepskins, and egg-crate mattresses are less expensive devices.
. Avoid agents that delay wound healing, such as topical corticosteroids, hydrogen peroxide, povidone iodine
solution, and hypochlorite solutions
. Avoid saline dressings that interrupt fragile wound healing
. Control of fecal and/or urine incontinence
. Inadequate data to support use of electromagnetic therapy
Specific measures by stage as follows:
. Stage I: Nonblanchable erythema of intact skin
. Relieve pressure (fl oatation or airfl ow mattress/bed)
. Use moisture barrier lubricant, transparent bio-occlusive dressings (Opsite) or Granulex Spray on reddened areas
. Keep all skin areas clean and dry
. Assess skin every 8-12 hours
. Stage II: Partial thickness skin loss of epidermis, dermis, or both; presents as abrasion, blister or crater
. Use dry 4 x 4fs to cleanse pressure sore followed by topical antibiotic
. Apply protective barrier fi lm to unbroken skin surrounding pressure sore
. Apply occlusive hydrocolloid dressing (Duoderm)
. Repeat every three days
. Loosely pack wound
. Whirlpools useful for debriding necrotic wounds
. Stage III: Full thickness skin loss through subcutaneous tissue down to but not through underlying fascia;
presents as deep crater with or without undermining adjacent tissue
. Scrub and debride with dry gauze and gels for autolytic debridement
. Re-rinse wound
. Blot excess moisture with dry 4 x 4 gauze
. Apply protective barrier fi lm
. Apply skin care product (occlusive hydrocolloid dressing, granules, or paste)
. If wound highly exudative, use absorption dressing (exudate absorbers) and change daily; consider wound culture
. For necrotic wounds, consider high-pressure injection using 35-mL syringe and 19-gauge angiocatheter
. Stage IV: Full thickness skin loss with exposure or destruction extended to muscle, bone and/or other
supportive structure
. If eschar present, needs debridement or wait for sloughing
. Blot excess moisture with 4 x 4 dry gauze
. Apply protective barrier fi lm to unbroken skin surrounding sore
. Moisten packing gauze (Kerlix) in saline and pack wound
. Apply outer dressing
. Negative pressure therapy (vacuum-assisted closure device)
. Surgical intervention for defi nitive treatment of deep and complicated pressure ulcers, such as myocutaneous flaps, split-thickness skin grafts and primary closure
SURGICAL MEASURES See under various stages in General Measures
ACTIVITY
. Any activity consistent with patientfs ambulatory status and relief of pressure on wound
. Perform passive range-of-motion exercises for patient or encourage patient to do active exercises if possible
DIET
. Oral high-calorie and high-protein supplements, including daily multivitamin with 100% RDA
. Vitamin A to aid epithelialization and fi broblast stimulation, vitamin C (500 mg/day) to aid collagen synthesis
and tensile strength, zinc (15 mg/day) for protein synthesis, copper for collagen production and cross-linking,
manganese for collagen and ground substance
ALTERNATIVE DRUGS
Miscellaneous treatments
• Calendula ointment or a 5% fl ower extract with allantoin stimulates new epithelial growth in surgical wounds
• Two drops of tea tree oil in 8 ounces of water - used as a rinse to decrease risk of infection
• Marshmallow root ointment over wound daily
• Nerve growth factor
• Electrical stimulation
• Anabolic hormones (injectable and oral) may promote weight gain, esp. LBM, limited evidence effective in
nonhealing wounds, consider testosterone, testosterone analogs (eg, oxandrolone), or growth hormone (IGF-1).
• Unproven alternate therapies include - sterile maggots, hyperbaric oxygen, low-energy laser irradiation, ultrasound therapy
PATIENT MONITORING
• Frequent evaluation of all patients with history of pressure sores, especially if limited mobility. Include
nutritional status and dietary intervention.
• Early identification of areas of skin redness to prevent subsequent breakdown
• Skin cleansing as soon as soiled and at routine intervals
• Home telemedicine to assess treatment
PREVENTION/AVOIDANCE
• Up to 95% of all pressure ulcers are preventable
• Assess nutrient status and provide required macro- and micronutrients, by oral route, enteral, or parenteral if
necessary
• Resistance exercise to speed up LBM growth
• Pressure reducing support surfaces (eg, high-density, 4 inch foam overlays)
• Keep the skin clean and dry by using mild soap, warm water and moisturizer
• Early identifi cation of at risk individuals and elimination of risk factors (risk assessment tools: Brader Scale
for Predicting Pressure Sore Risk for nursing home patients and The Norton Scale for hospitalized patients)
• Underpads (non-cloth) to absorb moisture
• Quality nursing care
• Early interdisciplinary supportive care - include staff, patient, family/caregiver
• Nutritional assessment of patient, 24-hour dietary recall and serum pre-albumin, especially if cannot take food
by mouth or has experienced involuntary change in weight
• Frequent patient repositioning if immobile - every hour if wheelchair bound and every 2 hours if bedridden
• Positioning devices
• Functional assessment of patient and treatment of incontinence
• Frequent physical examination of skin areas affected by pressure, moisture, shearing or friction sources
• Use mattress overlays, thick air seat cushions and high specification mattresses and beds to reduce pressure on pressure points, especially for hospitalized patients
POSSIBLE COMPLICATIONS
• Growth of resistant organisms if antibiotics used inappropriately
• Sepsis, cellulitis, septic arthritis, sinus tract or abscess, squamous cell carcinoma in ulcer
• Osteomyelitis in up to 25% of nonhealing ulcers
• Gangrene
• Increased incidence of death annually
EXPECTED COURSE/PROGNOSIS
• Though pressure ulcers are associated with an increased rate of mortality, with good medical care, most can be expected to heal
• In a recent study among long-term care hospital patients, 79% of pressure sores improved and 40%
completely healed during a six-week followup period using ordinary therapies