Review of Pressure Ulcers

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1562
Ulcers
(Last Updated On: February 23, 2017)

Pressure ulcers, also called decubitus ulcers, bedsores, or pressure sores are localized injuries to the skin or underlying tissue, usually over a bony prominence, as a result of unrelieved pressure. Pressure ulcers significantly threaten the well-being of patients with limited mobility. 70 percent of ulcers occur in persons older than 65 years; younger patients with neurologic impairment or severe illness are also susceptible

Predisposing factors

  • Intrinsic (e.g., limited mobility, poor nutrition, comorbidities,aging skin)
  • Extrinsic (e.g., pressure, friction, shear, moisture)

Etiology

Pressure ulcers are caused by unrelieved pressure,applied with great force over a short period (or with less force over a longer period)disrupting blood supply to the capillary network and impeding blood flow thus depriving tissues of oxygen and nutrients. This external pressure must be greater than arterial capillary pressure to lead to inflow impairment and resultant local ischemia and tissue damage. The common sites are over the sacrum, heels, ischial tuberosities,greater trochanters, and lateral malleoli.

NPUAP (The National Pressure Ulcer Advisory Panel) Staging System for Pressure Ulcers

Suspected deep tissue injury — Purple or maroon localized area of discolored, intact skin or blood-filled blister caused by damage to underlying soft tissue from pressure or shear; the discolouration may be preceded by tissue that is painful, firm, mushy, boggy,or warmer or cooler compared with adjacent tissue.

Stage 1 :

  • Intact skin with non-blanchable redness of a localized area,
  • Usually over a bony prominence
  • Dark pigmented skin may not have visible blanching and the affected area may differ from the surrounding area
  • The affected tissue may be painful, firm, soft, or warmer or cooler compared with adjacent tissue

Stage 2 :

Partial thickness loss of dermis appearing as a shallow, open ulcer with a red-pink wound bed, without slough,may also appear as an intact or open/ruptured serum-filled blister.

Stage 3 :

  • Full-thickness tissue loss, subcutaneous fat may be visible
  • Bone, tendon, or muscle is not exposed
  • Slough may be present but does not obscure the depth of tissue loss
  • May include undermining and tunneling

Stage 4 :

  • Full-thickness tissue loss
  • Exposed bone, tendon, or muscle
  • Slough or eschar may be present on some parts of the wound bed
  • Often includes undermining and tunneling

Unstageable:

Full-thickness tissue loss with the base of the ulcer covered by slough or eschar in the wound bed

Prevention

Preventive measures should be used in at risk patients. Pressure reduction to preserve microcirculation is a mainstay of preventive therapy. The Braden Scale is the most commonly used tool for predicting pressure ulcer risk. The evaluation is based on six indicators: sensory perception, moisture, activity, mobility, nutrition, and friction or shear.

To minimize shear, the head of the bed should not be elevated more than 30 degrees and should be maintained at the lowest degree of elevation needed to prevent other medical complications, such as aspiration and worsening congestive heart failure symptoms.

Patients can reduce pressure by repositioning themselves using manual aids, such as a trapeze bar.

Pressure reducing devices like foam, water, gel, and air mattresses, low–air-loss and air-fluidized surfaces chair cushions and pillows, foam wedges can reduce pressure or relieve pressure. Ring cushions can cause pressure points and should not be used.

Assessment

  • Complete medical evaluation of the patient
  • Nutritional and Skin care assessments
  • Vascular Assessment
  • Pain Assessment
  • Psychological health, behavioral and cognitive status assessment
  • Access to caregivers: The presence of a pressure ulcer may indicate that the patient does not have access to adequate services or support.

Note: The number, location, and size (length, width, and depth) of ulcers and assess for the presence of exudate, odor, sinus tracts, necrosis or eschar formation, tunneling, undermining, infection, healing (granulation and epithelialization), and wound margins and staging.

Management

The management of pressure ulcers is interdisciplinary,including primary care physicians, dermatologists, dietitians, podiatrists, wound-care nurses,physiotherapists,and surgeons. The cardinal methods are :

  • Reducing pressure on the skin
  • Debriding necrotic tissueand cleansing the wound
  • Managing bacterial load and colonization
  • Selecting appropriate wound dressing
  • Managing adequte nutritional and Energy Intake

Overview of different type of dressings

  • Transparent film : Management of stage I and II pressure ulcers with no exudate
  • Hydrogel wound Management : stages II, III, and IV ulcers, deep wounds,and wounds with necrosis or slough.
  • Alginate dressing : used as primary dressing for stages III and IV ulcers,wounds with moderate to heavy exudate or tunneling, and infected or noninfected wounds.
  • Foam dressing : used as primary dressing(to provide absorption andinsulation) or as secondary dressing (for wounds with packing) for stages II to IV ulcers with variable drainage
  • Hydrocolloid dressing : used as primary or secondary dressing for stages II to IV ulcers, wounds with slough and necrosis, or wounds with light to moderate exudate
  • Moistened gauze dressing : ,used for stages III and IV ulcers and for deep wounds

Note : Wound cleaning-Wound cleansing with antiseptic agents (e.g., povidone-iodine, Betadine,hydrogen peroxide, acetic acid) should be avoided because they destroy granulation tissue . Use of normal saline is preferred.

Complications

Noninfectious complications

  • Amyloidosis
  • Heterotopic bone formation
  • Perineal-urethral fistula
  • Pseudo-aneurysm
  • Marjolin ulcer

Infectious complications

  • Bacteremia
  • Sepsis
  • Cellulitis
  • Endocarditis
  • Meningitis
  • Osteomyelitis
  • Septic arthritis
  • Sinus tracts or abscesses

References

  1. Pressure Ulcers: Prevention,Evaluation, and Management by Daniel Bluestein,
  2. Garcia AD, Thomas DR. Assessment and management of chronic pressureulcers in the elderly
  3. Whitney J, Phillips L, Aslam R, et al. Guidelines for the treatment of pressure ulcers.

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