05. Pressure Ulcers

Definition

A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure in combination with shear and/or friction.

  • Pressure ulcers that develop during a hospital stay are considered “never events,” and as of 2009 the Department of Human Services has made reported ulcers (mandatory reporting since 2007) available to the public.
  • The incidence of pressure ulcers varies in studies from 0.4% to 38% of acute care patients with an estimated 2.5 million pressure ulcers treated each year in US acute care facilities.
  • Having a pressure ulcer resulted in a median excess length of stay of 4.3 days.

Common Pressure Point Locations

Evaluation

Identify patients who are at high risk. Risk factors include:

  • Immobility
  • Age >75
  • Braden scale ≤16
  • Prior pressure ulcer
  • Decreased sensation or paralysis
  • Dementia
  • Diabetes mellitus
  • Poor Tissue Perfusion
  • Incontinence (urinary or fecal)
  • Decreased body weight
  • Malnutrition (low albumin/BMI)
  • Pain at bony prominence
  • Recent operation (within last 5 days)
  • Terminal illness/Metastatic cancer
  • Vascular disease (esp. prior amputation)

Assessment:

  1. Assess and document initial skin exam on all patients
    1. If presenting from home, consider elder abuse/neglect or self-neglect
  2. Document the stage (see www.npuap.org for examples): Note that stage is based on anatomical structures involved (skin, subcutaneous tissue, muscles, etc.) rather than absolute depth.
    1. Stage I: Intact skin with non-blanchable 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. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.
    2. 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 ruptured serum-filled blister or as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.  
    3. 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. The area may include undermining and tunneling. Of note, the depth varies by anatomical location; stage III ulcers may be quite deep in areas with adiposity but may be quite shallow in areas with little subcutaneous tissue (occiput, malleolus, etc.).
    4. 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. The area often includes undermining and tunneling. Stage IV ulcers can extend into muscle and/or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. 
    5. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. The true depth, and therefore stage, cannot be determined until this slough/eschar is removed. However, stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should NOT be removed.
    6. Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled 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. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid (seemingly go from intact skin to deep ulcer) exposing additional layers of tissue even with optimal treatment.   
  3. Measure size and document in record on admission and discharge.
  4. Monitor for evolution and complications: local infection, osteomyelitis, bacteremia, sinus tract.

Treatment

  • Treatment of ulcers vary by stage, location, and characteristics (e.g. moisture, infection).
  • No single topical agent or support surface has been shown superior and formularies/available supplies vary.
  • Obtain wound care nurse consult.
  • To prevent new ulcers:
    • Reposition patient q1-2 hrs
    • Use pressure relief and heel relief modes on Hill-Rom beds/air mattress
    • Float heels with pillow, or for knee ulcers use a cradle to elevate blanket
    • If incontinent, change pad/diaper frequently and apply moisture barrier to skin (Aloe Vesta for intact skin; Sensicare for non-intact skin)
    • Encourage patient to be OOB, but avoid prolonged sitting in one position for >1 hr

 

Grey JE, Harding KG, Enoch S. Pressure ulcers. BMJ 2006; 332 (7539): 472-5

Reddy et al. “Preventing Pressure Ulcers: A Systematic Review.” JAMA 2006; 296(8)                                                                                                                                   

“Pressure Ulcer Prevention Points.”  National Pressure Ulcer Advisory Panel.  www.npuap.org.  2007.

Reddy M, Gill SS, Kalkar SR, Wu W, Anderson PJ, Rochon PA. Treatment of pressure ulcers: a systematic review. JAMA 2008; 300 (22):2647-62