Pressure Sores

1. Pressure Ulcers
Jorge G. Ruiz, MD, FACP
Division of Gerontology and Geriatric Medicine
University of Miami School of Medicine

2. Pressure Ulcers
Epidemiology
Definition and Location
Classification
Pathogenesis and Risk Factors
Prevention
Treatment
Pressure Ulcers treatment for each stage
Complications

3. Epidemiology

4. Pressure Ulcers
Epidemiology
1-3 million Americans are affected
Health care expenditures: $ 5 billion/year
More than 17,000 lawsuits related to
pressure Ulcers are filed annually
1 in 4 persons in the USA who died in
1987 had a dermal ulcer
Pressure Ulcers develop primarily in
elderly patients

5. Pressure Ulcers
Epidemiology
Setting
Hospital 60%
Nursing homes 18%
Home 18%
1/3 of patients undergoing surgery for hip
fracture develop a pressure ulcer
The longer the patient stays in a nursing
home, the greater the likelihood of developing
a pressure ulcer

6. Definition and Location

7. Pressure Ulcers
Definition
Pressure Ulcers are localized areas of
tissue necrosis that tend to occur when
soft tissue is compressed between a bony
prominence and an external surface for a
prolonged period.
These lesions are also called bedsores,
decubitus ulcers and pressure sores

8. Pressure Ulcers
Location
Pressure ulcers commonly occur over the :
Sacrum
Greater trochanter
Ischial tuberosity
Malleolus
Heel
Fibular head
Scapula

10. Areas of pressure

11. Classification

12. Pressure Ulcers / Classification
National Pressure Ulcer Advisory Panel
Stage 1: non blanchable erythema of intact skin
Stage 2: partial thickness skin loss that involves
the epidermis or dermis (or both)
Stage 3: full thickness skin loss and damage or
necrosis of subcutaneous tissue that may
extend to, but not through, underlying fascia
Stage 4: full thickness skin loss associated with
extensive destruction, tissue necrosis, or
damage to muscle, bone, or supporting
structures, such as tendons or joint capsules

14. Stage 1
The heralding lesion of skin ulceration

16. Stage 2
The ulcer is superficial and manifest clinically
as an abrasion, blister or shallow crater

18. Stage I-II Pressure sore

19. Stage 3
The ulcer manifests clinically as a deep crater
with or without undermining of adjacent
tissue

21. Stage 4
A
B

23. Stage IV Pressure sore

24. Pressure Ulcers
Staging. Limitations
Staging definitions recognize these assessment
limitations:
Identification of Stage I pressure ulcers may be
difficult in patients with darkly pigmented skin.
When eschar is present, accurate staging of the
pressure ulcer is not possible until the eschar
has sloughed or the wound has been debrided.

25. Pathogenesis and Risk
Factors

26. Pressure Ulcers
Pathogenesis
Four key factors:
Pressure
Shearing forces
Friction
Moisture

27. Pathogenesis

28. Pressure Ulcers
Risk Factors
Spinal cord injuries
Traumatic brain injury
Neuromuscular disorders
Immobility
Malnutrition
Fecal and urinary
incontinence
Altered level of
consciousness
Chronic systemic illness
Fractures
Aging skin
decreased epidermal
turnover
dermoepidermal junction
flattens
fewer blood vessels
Decreased pain
perception

29. Prevention

30. Pressure Ulcers
Risk Assessment
Select and use a method of risk assessment that
ensures systematic evaluation of individual risk
factors.
Many risk assessment tools exist, but only the
Norton Scale and Braden Scale have been
tested extensively.
Tools include the following risk factors: mobility/
activity impairment, moisture, incontinence, and
impaired nutrition.

31. Pressure Ulcers
Activity or Mobility Deficit
Bed- or chair-bound individuals or those whose
ability to reposition is impaired should be
considered at risk for pressure ulcers.
Identification of additional risk factors
(immobility, moisture/incontinence, and
nutritional deficit) should be undertaken to direct
specific preventive treatment regimes.

32. Pressure Ulcers
Educational Program
Educational programs for the prevention
of pressure ulcers should be:
Structured
Organized
Comprehensive
Directed at all levels of health care providers,
patients, and family or caregivers. .

33. Pressure Ulcers
Reassessment
Active, mobile individuals should be
periodically reassessed for changes in
activity and mobility status.
The frequency of reassessment depends
on patient status and institutional policy.

34. Pressure Ulcers/Mechanical
Loading and Support Surfaces
For bed-bound individuals:
Reposition at least every 2 hours.
Use pillows or foam wedges to keep bony
prominences from direct contact.
Use devices that totally relieve pressure
on the heels.
Avoid positioning directly on the
trochanter.

35. Pressure Relieving Devices

36. Pressure Relieving Boot

37. Pressure Ulcers/Mechanical Loading
and Support Surfaces
Elevate the head of the bed as little and
for as short a time as possible.
Use lifting devices to move rather than
drag individuals during transfers and
position changes.
Place at-risk individuals on a pressure-
reducing mattress.
Do not use donut-type devices.

38. Pressure Ulcers/Mechanical Loading
and Support Surfaces
For chair-bound individuals:
Reposition at least every hour.
Have patient shift weight every 15 minutes
Pressure-reducing devices for seating surfaces.
Do not use doughnut-type devices.
Consider postural alignment, distribution of
weight, balance and stability, and pressure
relief when positioning individuals in chairs or
wheelchairs.

39. Pressure Ulcers
Skin Care and Early Treatment
Inspect skin at least once
a day.
Individualize bathing
schedule (Avoid hot
water and mild cleansing
agent)
Minimize environmental
factors such as low
humidity and cold air.
Use moisturizers for dry
skin
Avoid massage over bony
prominences.
Use proper positioning,
transferring, and turning
techniques.
Use lubricants to reduce
friction injuries.
Rehabilitation program.
Monitor and document
interventions/outcomes.

40. Pressure Ulcers
Nutritional Deficit
Investigate factors that compromise an
apparently well-nourished individual's
dietary intake.
Plan and implement a nutritional support
and/or supplementation program for
nutritionally compromised individuals.

41. Treatment

42. Assessment
History and Physical Examination
Assessing Complications
Nutritional Assessment and Management
Pain Assessment and Management
Psychosocial Assessment and
Management

43. Pressure Ulcers
Ulcer care
The four basic components
2.debridement of necrotic tissue as needed on
initial and subsequent assessments
3.cleansing the wound initially and with each
dressing change
4.prevention, diagnosis, and treatment of infection
5.using a dressing that keeps the ulcer bed moist
and the surrounding intact tissue dry

44. Debridement
Moist, devitalized tissue supports the growth of
pathological organisms.
Therefore, the removal of such tissue favorably
alters the healing environment of a wound.
Removal of devitalized tissue is considered
necessary for wound healing
It has not been studied in a randomized trial.

45. Eschar tissue

46. Eschar tissue

47. Granulating tissue & necrotic
tissue

48. Wound Cleansing
Remove necrotic tissue, exudate, and metabolic
wastes from the wound.
Minimum of chemical and mechanical trauma. .
Cleanse wounds initially and at each dressing
change
Do not clean ulcer wounds with skin cleansers
or antiseptics
Use normal saline for cleansing
Consider whirlpool treatment for ulcers that
contain thick exudate, slough, or necrotic tissue.

49. Dressings
Keep the ulcer bed continuously moist.
Wet-to-dry dressings should be used only
for debridement
No differences in pressure ulcer healing
outcomes with diverse dressings
Keep the surrounding intact (periulcer)
skin dry while keeping the ulcer bed moist.

50. Dressings
Control exudate but do not desiccate the
ulcer bed.
Consider caregiver time
Eliminate wound dead space by loosely
filling all cavities with dressing material.
Avoid overpacking the wound.
Monitor dressings applied near the anus

51. Adjunctive Therapies
The therapies included :
electrical stimulation
hyperbaric oxygen
infrared and ultraviolet light
low-energy laser irradiation
ultrasound
miscellaneous topical agents (including cytokine
growth factors)
systemic drugs other than antibiotics

52. Pressure Ulcers
Treatment for each stage

53. Stage 1
Intensive implementation of preventive
measures as usual
Polyurethane dressings (transparent) applied
every 1 to 10 days (Tegadermâ)
They are semipermeable films, permeable to
water vapor, oxygen and other gases and
impermeable to water and bacteria
Most lesions can be expected to heal by 2
weeks

54. Stage 2
The same as for stage I but…
Wound should be inspected for signs of
infection
Polyurethane dressings are more effective
and less costly than wet-to-dry dressings
(Tegaderm â or thin Duoderm â)
Wet-to-dry dressings are rarely indicated
at this stage

55. Stage 3
Remove necrotic material
Small eschar:
Debridement by experienced PCP
Topical application of enzymatic debriding agents
Eschar should be scored
Enzymes must not touch surrounding
areas
Large eschar: Surgical consultation

56. Stage 3
Loose material can be debrided with wet-to-dry
dressings every 8 hours
Polyurethane and hydrocolloid dressings
(Duodermâ) are more effective
Hydrocolloids are impermeable to gas and
moisture and are changed every 1-4 days
Deeper stage 3 or 4: Wounds need to be packed
with material depending on exudate

57. Stage 3
Hydrocolloid dressings are not
appropriate
Dry wounds: less absorptive Hydrogels or
moist soaks with normal saline
Exudative wounds: Absorptive dressings
such as Hydrophilic foam alginates
(Kaltostat â) or saline impregnated gauze
Packings are changed daily

58. Stage 3
Consider specialized beds:
air fluidized beds
low-air-loss beds
They should be used for at least 60 days
Patients with large defects: surgery consult
Patients with large defects in the sacral area and
urinary incontinence may require catheterization

59. Low Air Loss Mattress

60. Stage 4
They require surgical consultation for
initial debridement
Wet-to-dry dressings may help
Whirlpool baths may facilitate debridement
Clean deep ulcers require packing
Consider grafting procedures
Always keep in mind the goals of the
patient

61. Managing Bacterial Colonization
and Infection
Stage 2, 3 and 4 pressure ulcers are invariably
colonized with bacteria.
In most cases, adequate cleansing and
debridement prevent bacterial colonization from
proceeding to the point of clinical infection
If purulence or foul odor is present, more
frequent cleansing and possibly debridement
are required.

62. Infected Pressure Sore

63. Managing Bacterial Colonization
and Infection
Do not use swab cultures to diagnose wound
infection (colonization)
Consider 2-week trial of topical antibiotics for
clean pressure ulcers that are not healing or
producing exudate
Effective against gram negative, positive, and
anaerobes
Perform quantitative bacterial cultures of soft
tissue and evaluate for osteomyelitis when ulcer
does not respond to topical antibiotic therapy.

64. Managing Bacterial Colonization
and Infection
Systemic antibiotic therapy for patients with
bacteremia, sepsis, advancing cellulitis, or
osteomyelitis.
Do not use topical antiseptics (povidone iodine,
iodophor, Dakins® solution, hydrogen peroxide,
acetic acid) to reduce bacteria in wound tissue.
Systemic antibiotics are not required for
pressure ulcers with signs of local infection.
Protect pressure ulcers from exogenous sources
of contamination

65. Infection Control
Follow body substance isolation precautions or
an equivalent system.
Use clean gloves for each patient.
When treating multiple ulcers on the same
patient, attend to the most contaminated ulcer
last
Use sterile instruments to debride ulcers
Use clean dressings, rather than sterile ones, to
treat pressure ulcers.

66. Operative Repair of Pressure
Ulcers
Operative procedures to repair pressure
ulcers include one or more of the
following:
 Direct closure
Skin grafting
Skin flaps
Musculocutaneous flaps
Free flaps.

67. Operative Repair of Pressure
Ulcers
Consider for operative repair when clean Stage
III-IV do not respond to optimal patient care
Candidates are medically stable, well nourished
and can tolerate operative blood loss and
postop immobility.
Correct factors that may be associated with
impaired healing (smoking, spasticity, levels of
bacterial colonization, incontinence, and UTI)
Minimize pressure to the operative site by use of
special beds

68. Assessment of Ulcer Healing
Evaluate at least weekly
If general condition deteriorates, the ulcer
should be reassessed promptly
Evaluate using size, depth, presence of exudate,
epithelialization, granulation tissue, necrotic
tissue, sinus tracts, undermining, tunneling,
purulent drainage or signs of infection.
A clean pressure ulcer with adequate
innervation and blood supply should show
progress toward healing in 2 to 4 weeks

69. Monitoring
Healing ulcers should be assessed regularly
Monitor the individual's general health,
nutritional status, psychosocial support, pain
level and be alert to signs of complications
The frequency of monitoring should be
determined by the clinician based on the
condition of the patient, ulcer, rate of healing,
and the health care setting.

70. Complications

71. Pressure Ulcers
Complications
Amyloidosis
Endocarditis
Heterotopic bone
formation
Maggot infestation
Meningitis
Perineal-urethral fistula
Pseudoaneurysm
Septic arthritis
Sinus tract or abscess
Squamous cell carcinoma
in the ulcer
Systemic complications of
topical treatment
Osteomyelitis
Bacteremia
Advancing cellulitis