Pressure Ulcers

Epidemiology

• • Typically occur within 2 wks of hospitalization, and can develop within 2 - 6 hrs. 63% increase in incidence in the last decade. Once the develop, pressure ulcers are difficult to treat.

Prevention: key to management.

• • Risk factor assessement: immobility, limited activity, incontinence, impaired nutritional status, impaired circulation, and altered level of consciousness.

  • Skin care: Daily inspection and attention to bony prominences and minimize exposure to moisture from incontinence, perspiration, or wound drainage. Moisturizers applied to dry sacral skin. Nutrition supplement to patient at risk.

  • Relieve or redistribute pressure, change postition q2h, or q1 h for wheel-chair bound pt. pillows, foam wedges between bony prominences, maintenance of the head of bed at the lowest degree of elevation, use of lifting devices when moving pts. pressure reducing devices (foam, dynamic air mattress) and pressure relieving devices (low-air-loss, air-fluidized beds).

Diagnosis:

Physical exam: National Pressure Ulcer Advisory Panel Staging:

• • Suspected deep tissue injury: Purple or maroon localized area of discolored intact skin or blood-fluid blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.

  • Stage I: Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

  • Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

  • Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

  • Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

  • Unstageable: full thickness tissue loss in which base of the ulcer is covered by slough (yellow, tan, grey, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.

Treatment:

• • Pressure relieving devices, occlusive dressings, pain control, normal saline for cleansing, use of topical agents that promote wound healing (DuoDerm, silver sulfadiazine, bacitracin zinc, Neosporin, Polysporin), avoidance of agents that delay healing (antiseptic agents, such as Dakin solution, hydrogen peroxide; wet-to-dry gauze), and removal of necrotic debris.

  • Adequate nutrition with particular attention to protein intake, 1.25 to 1.50 gm protein/kg/day), vitamin C, 500 mg PO daily; zinc sulfate, 220 mg PO daily supplementation in the presence of deficiencies may also facilitate healing.

  • For clean pressure ulcers that continue to produce exudate or are not healing after 2 - 4 weeks of therapy, consider a 2-week trial of topical Abx (silver sulfadiazine, double antibiotic).

  • Other adjunctive therapies for non-healing ulcers include electrical stimulation, radiant heat, negative pressure therapy, and surgical interventions.