Contents

Search

pressure ulcer (decubitus ulcer, bedsore)

Any lesion caused by unrelieved pressure resulting in damage of underlying tissue. Classification: - see staging of pressure ulcers Etiology: 1) extrinsic factors a) pressure b) shear forces c) moisture d) chemical irritants 2) host (intrinsic) risk factors: a) debilitating systemic disease b) immobility & inactivity, flaccid paralysis - spinal cord injury & neurologic disease c) incontinence, urinary incontinence & fecal incontinence d) malnutrition, low serum albumin < 3.0 g/dL - morbid obesity & low BMI e) febrile illnesses, infections f) altered mental status g) diminished sensation h) fracture i) hypotension j) hypovolemia k) anemia l diabetes mellitus [41] m) increased metabolic demands n) advanced age o) immunosuppression [9] Epidemiology: 1) acute care hospital a) all patients 3-11% b) bed-bound patients 28% (for 1 week) c) ICU patients: 22-29/1000 patient days d) likelihood of pressure sores inversely correlated with frequency of repositioning 2) nursing home residents a) 11-56% of new nursing home residents b) mortality for nursing home patient with pressure ulcer is 2-6 times that for patients without c) prevalence higher in blacks than whites [11] - persons with darker skin at risk of later detection of pressure injury - nonblanching erythema in darker-skinned populations may be difficult to detect [8,46] 3) heels & sacrum are most common sites for pressure ulcers Pathology: 1) pressure a) capillary filling pressure is about 32 mm Hg* b) when pressure between support surface & bony prominence is > 32 mm Hg, blood flow stops c) ischemia, acidosis, toxin accumulation, hemorrhage into interstitium & cell death occur d) eventually intrinsic fibrinolysis diminishes & intra- vascular coagulation further compromises perfusion even after pressure is relieved e) pressure is more easily distributed in superficial tissue thus deeper tissues may be more vulnerable f) tissue damage apparent 1-2 hr of 60 mm Hg; pressure > 70 mm Hg for 2 hr causes irreversible tissue damage g) average sacral pressure on standard hospital mattress is 150 mm Hg h) highest pressure over ischial tuberosity in chair-bound person (150-500 mm Hg) [8] i) high pressure over the posterior heel in immobile supine person [49] 2) friction a) removal of stratum corneum & damage to underlying layers b) can occur with moving patients against bedding (use drawsheet) 3) shear a) friction holds skin in place, but gravity pulls axial skeleton down b) results in stretching of perforating arterioles & compromise of dermal perfusion 4) moisture -> causes softening of stratum corneum with exacerbates effects of friction * 32 mm Hg measured from human cuticular capillaries * different tissues may tolerate different pressures Clinical manifestations: * images [34] Laboratory: - complete blood count (hemoglobin/hematocrit) - serum albumin, hemoglobin A1c [41] - culture a) avoid culturing wound unless you plan to treat (all pressure ulcers are colonized with bacteria) b) swab technique more practical than tissue biopsy c) needle aspiration Special laboratory: - pulse oximetry - ankle-brachial index - doppler ultrasound (arterial vs venous) Radiology: - suspected osteomyelitis - confirm diagnosis & extent of disease with imaging prior to bone biopsy [9] - plain radiography (X-ray) preferred initial imaging test - if negative MRI necessary to confirm or exclude osteomyelitis - CT if MRI not feasible (see osteomyelitis) Complications: - osteomyelitis [33] Differential diagnosis: - arterial ulcer (management is very different) - venous ulcer [41] - skin tears [41] - medical adhesive related skin injury (MARSI) [41] - dermatitis [41] - moisture associated skin damage (MASD) [41] - excoriation [41] - wound related to malignancy [41] Management: 1) pressure ulcer assessment - use of pressure ulcer risk assessment tool associated with lower risk for development of pressure ulcers - use pressure sore status tool to assess at baseline, then at regular intervals to assess healing - characterizing risk of skin breakdown using formal risk assessment tool will not prevent progression of pressure ulcer [49] - use of risk assessment scales versus clinical judgment not evidence based [32] - pressure ulcer staging 2) general measures a) avoid pressure on bony prominences - ischial tuberosity (wheel chair) - greater trochanter (30 degree angle from supine) - heels (supine); use soft booties, pillow under calves b) pressure relief [13], pressure redistribution [9]; also see support surface - pressure redistribution mattresses for all long-term care residents [12] - advanced static mattress or static overlay for at-risk patients [3,9,32] - alternating-pressure air mattress or overlay expensive with no proven benefit over static mattress [32] - low air loss mattress - air-fluidized beds - high-density foam mattress [30] - no difference in pressure ulcer incidence over 3 weeks between those turned at 2-, 3-, or 4-hour intervals [30] - no evidence for benefit of sheepskin or egg crate mattress - specialized foam mattress overlays on operating tables - do NOT use doughnuts - pressure offloading c) repositioning probably of no benefit - no difference in pressure ulcer incidence over 3 weeks between those turned at 2-, 3-, or 4-hour intervals with high-density foam mattress [30] - recommendation in the absence of high-density foam mattress - no good evidence supports repositioning alone for pressure ulcer prevention [9] - repositioning every 4 hours has not been shown to reduce pressure ulcers [8] - reposition every 2 hours (every hour for chair-bound* individuals) - special support surfaces may allow for repositioning less frequently than every 2 hours [8] d) use drawsheet when moving patients to avoid friction e) adequate nutrition - dietary protein 1.5-2.0 g/kg/day [8]; 100 g/day [8] - evidence for dietary intervention in healthy elderly (not-malnourished) is lacking [8] - ref [24] cites benefit of micronutrient-enriched oral nutritional supplement in non-malnourished patients - protein supplements enriched with arginine, zinc, & antioxidants - improve healing of pressure ulcers in malnourished patients (61% vs 45% (control) 8 week reduction in pressure ulcer size) [8,31,47] - use protein or amino acid supplements decrease pressure ulcer size [32] - a feeding tube does not prevent or improve healing of pressure ulcers & may increase risk of pressure ulcers in nursing home residents with advanced dementia [36] f) control moisture: incontinence management, barrier creams g) skin care - mild cleansers (normal saline) - moisturizing agents - remove excess skin secretions, excretions - perineal foam cleansers & dry skin emollients appear to be cost-effective prevention measures [12] - keepin skin clean & dry acceptable h) treat pain associated with dressing changes [27] i) early mobilization - moving immobile patient to bedside chair should be limited to 2 hours j) in-service educational programs k) interventions to prevent pressure ulcers are much more cost-effective than treatment of pressure ulcers [9] l) 40% of pressure ulcers in critically ill patients may be unavoidable [40] m) silver alginate or silver sulfadiazine for infected wounds (GRS9) [8,41] n) routine use of topical phenytoin, silver preparations, or growth factors is not recommended [19] o) hyperbaric oxygen therapy without evidence of benefit [9] p) hydrotherapy of no benefit [9] 3) stage I (see staging of pressure ulcers) a) cleanse with non-drying soap & water b) no dressing indicated 4) stage II a) goals - moist wound bed & dry surrounding skin - minimize pain b) cleanse with normal saline c) dressing - polyurethane foam - foam wafers (Mepilex) - hydrogel wafers (Restore) - hydrocolloid wafers (Restore) - appropriate for partial-thickness pressure ulcers [8] 5) stages III & IV without necrosis a) goals - moist wound bed & dry surrounding skin - minimize pain b) normal saline irrigation c) dressing - if shallow (>= 1 cm), use hydrogel wafers, polyurethane foam, foam wafers - if dead space, use hydrogel dressing - prior to hydrogel dressings - lightly fill with saline-moistened gauze, kept continuously moist - remoisten gauze before removal if dried & adhered to tissue d) topical phenytoin may enhance wound healing e) surgical excision & primary closure may be option [7] - patients with deep wounds, without infection - good nutritional status - able to comply with frequent repositioning f) negative pressure wound therapy for wound not responding to conventional therapy [8] 6) stage III & IV with necrosis &/or excessive exudate a) goals - debridement of necrotic tissue - minimize damage to granulating tissue - keep surrounding skin intact & dry - treat pain b) debridement - advancing cellulitis, bacteremia or sepsis - prompt sharp debridement - eschar: - debridement for evidence of infection, inspect daily - a stable, dry eschar in the absence of infection does not need debridement - not even with autolytic means such as with a hydrocolloid sheet [8] - especially if suspected vascular disease - eschar may serve as a barrier to infection [1,8] - if sacral decubitus ulcer is unstageable due to eschar, debridement is indicated [9] - softening with occlusive dressing may assist debridement - slough - enzymatic or autolytic debridement - may be combined with whirlpool - negative pressure wound therapy may remove remnants [8] c) saline irrigation 4-15 PSI - 250 mL squeeze bottle - Water Pik (dental irrigatory) at lowest setting - 35 mL syring with 19 gauge angiocatheter d) dressing - use hydrocolloid dressing or foam dressing to reduce pressure ulcer size [32] - use Silvadene dressing on infected wounds [8] - wet to dry dressing; loosely fill dead space; do NOT moisten before removal - after sharp debridement with bleeding, dry dressing for the 1st 8-24 hours; moisten before removal - if excessive exudate - alginate or other highly absorptive dressing - silver alginate on infected wounds with excessive exudate [8] - alternatively, more frequent dressing changes - protect surrounding skin with moisture barrier ointment - if malodorous or purulent exudate - topical antimicrobial agents - use Silvadene dressing on infected wounds [8] - if cellulitis, treat with systemic antibiotics - once necrosis is no longer present, stop debridement & use continuously moist saline dressing e) negative pressure wound therapy for wound not responding to conventional therapy [8] 7) unstageable pressure ulcer - debridement of unstageable sacral decubitus ulcer [9] 8) deep tissue injury a) determining the extent of tissue damage is not possible b) limit extension of ulcer through preventive strategies (see general measures above) [19] c) treat pain 9) osteomyelitis due to pressure ulcer - confirm diagnosis & extent of disease with imaging prior to bone biopsy [9] - plain radiography (X-ray) preferred initial imaging test - if negative MRI necessary to confirm or exclude osteomyelitis - CT if MRI not feasible (see osteomyelitis) - combined medical-surgical therapy reduces hospital readmissions [33] 10) palliative care of pressure ulcers [26] - reduce odor from deep pressure ulcers - frequent cleansing - topical metronidazole gel or silver sufadiazine [8,41] - treat pain from pressure ulcers - in some cases topical agents can reduce pain [27] - absorbent wound dressing (gauze dressing > hydrogel dressing) - reduce dressing changes 11) investigational - consider autologous platelet-rich plasma therapy [42] - no evidence for benefit of electromagnetic therapy [18] - electrical stimulation may be added to standard treatment to accelerate wound healing [32] * weight shift every 15 minutes for chair-bound patients * written plan with participation of occupational therapy [8]

Related

pressure ulcer assessment pressure ulcer risk scale staging of pressure ulcers

Specific

diabetic foot ulcer; diabetic foot lesion; diabetic lower extremity lesion foot ulcer Kennedy terminal ulcer pressure ulcer stage 1 pressure ulcer stage 2 pressure ulcer stage 3 pressure ulcer stage 4 pressure ulcer unstageable

General

cutaneous ulcer pressure injury

References

  1. nlmpubs.nlm.nih.gov/hstat/ahcpr/
  2. Goode PS and Thomas DR Pressure ulcers. Local wound care. Clinics in Geriatric Medicine 13(3):543, 1997 PMID: 9227943
  3. Cervo FA, Cruz AC, Posillico JA Pressure ulcers. Analysis of guidelines for treatment and management. Geriatrics 55:55, 2000 PMID: 10732005
  4. Klitzman B1, Kalinowski C, Glasofer SL, Rugani L. Pressure ulcers and pressure relief surfaces. Clinics in Plastic Surgery 25:443, 1998 PMID: 9696904
  5. Patterson JA, Bennett RG. J Am Geriatr Soc. 1995 Aug;43(8):919-27. Prevention and treatment of pressure sores. PMID: 7636103
  6. Roof L, UCLA Dept. of Nursing Clinical Standard, ref # 11, 1997
  7. Bates-Jensen BM. In: UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  8. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004 - Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010 - Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  9. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  10. Management and Treatment of Pressure Ulcers includes recommendations from AMDA, CSCM, Singapore MOH, RNAO, UIGN, and WOCN. http://www.guideline.gov/Compare/comparison.aspx?file=PRESSURE_ULCER_TREATMENT1.inc - Pressure Ulcer Prevention includes recommendations from JHF, NCCNSC/NICE, RNAO, UIGN, and WOCN http://www.guideline.gov/Compare/comparison.aspx?file=PRESSURE_ULCER_PREVENTION1.inc
  11. Li Y et al. Association of race and sites of care with pressure ulcers in high-risk nursing home residents. JAMA 2011 Jul 13; 306:179 PMID: 21750295
  12. Pham B et al Preventing pressure ulcers in long-term care: a cost- effectiveness analysis. Arch Intern Med. 2011 Nov 14;171(20):1839-47 PMID: 21949031
  13. McInnes E, Jammali-Blasi A, Bell-Syer SE et al Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev. 2011 Apr 13;(4): PMID: 21491384
  14. McInnes E, Dumville JC, Jammali-Blasi A, Bell-Syer SE. Support surfaces for treating pressure ulcers. Cochrane Database Syst Rev. 2011 Dec 7;(12):CD009490 PMID: 22161450
  15. Reddy M, Gill SS, Kalkar SR, Wu W, Anderson PJ, Rochon PA. Treatment of pressure ulcers: a systematic review. JAMA. 2008 Dec 10;300(22):2647-62 PMID: 19066385
  16. Baumgarten M, Margolis DJ, Localio AR et al Extrinsic risk factors for pressure ulcers early in the hospital stay: a nested case-control study. J Gerontol A Biol Sci Med Sci. 2008 Apr;63(4):408-13. PMID: 18426965
  17. Heyman H, Van De Looverbosch DE, Meijer EP, Schols JM. Benefits of an oral nutritional supplement on pressure ulcer healing in long-term care residents. J Wound Care. 2008 Nov;17(11):476-8, 480. PMID: 18978686
  18. Aziz Z, Flemming K. Electromagnetic therapy for treating pressure ulcers. Cochrane Database Syst Rev. 2012 Dec 12;12:CD002930. PMID: 23235593
  19. Mao CL, Rivet AJ, Sidora T, Pasko MT. Update on pressure ulcer management and deep tissue injury. Ann Pharmacother. 2010 Feb;44(2):325-32. PMID: 20118142
  20. Pieper B, Langemo D, Cuddigan J Pressure ulcer pain: a systematic literature review and national pressure ulcer advisory panel white paper. Ostomy Wound Manage. 2009 Feb;55(2):16-31. PMID: 19246782
  21. Sprigle S, Sonenblum S. Assessing evidence supporting redistribution of pressure for pressure ulcer prevention: a review. J Rehabil Res Dev. 2011;48(3):203-13. Review. PMID: 21480095
  22. Banks M, Bauer J, Graves N, Ash S. Malnutrition and pressure ulcer risk in adults in Australian health care facilities. Nutrition. 2010 Sep;26(9):896-901. PMID: 20018484
  23. Litchford MD, Dorner B, Posthauer ME. Malnutrition as a Precursor of Pressure Ulcers. Adv Wound Care (New Rochelle). 2014 Jan 1;3(1):54-63. Review. PMID: 24761345 - Dorner B, Posthauer ME, Thomas D; National Pressure Ulcer Advisory Panel The role of nutrition in pressure ulcer prevention and treatment: National Pressure Ulcer Advisory Panel white paper. Adv Skin Wound Care. 2009 May;22(5):212-21. PMID: 19521288
  24. van Anholt RD, Sobotka L, Meijer EP et al Specific nutritional support accelerates pressure ulcer healing and reduces wound care intensity in non-malnourished patients. Nutrition. 2010 Sep;26(9):867-72 PMID: 20598855
  25. Black JM, Edsberg LE, Baharestani MM et al Pressure ulcers: avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound Manage. 2011 Feb;57(2):24-37 PMID: 21350270
  26. Langemo DK, Black J; National Pressure Ulcer Advisory Panel. Pressure ulcers in individuals receiving palliative care: a National Pressure Ulcer Advisory Panel white paper. Adv Skin Wound Care. 2010 Feb;23(2):59-72. PMID: 20087072
  27. Pieper B, Langemo D, Cuddigan J Pressure ulcer pain: a systematic literature review and national pressure ulcer advisory panel white paper. Ostomy Wound Manage. 2009 Feb;55(2):16-31. PMID: 19246782
  28. Yastrub DJ. Pressure or pathology: distinguishing pressure ulcers from the Kennedy terminal ulcer. J Wound Ostomy Continence Nurs. 2010 May-Jun;37(3):249-50. PMID: 20463542
  29. Shahin ES, Dassen T, Halfens RJ. Pressure ulcer prevention in intensive care patients: guidelines and practice. J Eval Clin Pract. 2009 Apr;15(2):370-4. PMID: 19335499 - Shahin ES, Dassen T, Halfens RJ. Incidence, prevention and treatment of pressure ulcers in intensive care patients: a longitudinal study. Int J Nurs Stud. 2009 Apr;46(4):413-21. PMID: 18394626
  30. Bergstrom N, Horn SD, Rapp MP, et al. Turning for ulcer reduction: a multisite randomized clinical trial in nursing homes. J Am Geriatr Soc. 2013;61:1705-1713. PMID: 24050454
  31. Cereda E et al A Nutritional Formula Enriched With Arginine, Zinc, and Antioxidants for the Healing of Pressure Ulcers: A Randomized Trial. Ann Intern Med. 2015;162(3):167-174 PMID: 25643304 http://annals.org/article.aspx?articleid=2107745
  32. Qaseem A, Mir TP, Starkey M et al Risk Assessment and Prevention of Pressure Ulcers: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2015;162(5):359-369 PMID: 25732278 http://annals.org/article.aspx?articleid=2173505 - Qaseem A, Humphrey LL, Forciea MA et al Treatment of Pressure Ulcers: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2015;162(5):370-379 PMID: 25732279 http://annals.org/article.aspx?articleid=2173506 - Black J Pressure Ulcer Prevention and Management: A Dire Need for Good Science. Ann Intern Med. 2015;162(5):387-388 PMID: 25732284 http://annals.org/article.aspx?articleid=2173511
  33. Bodavula P et al. Pressure ulcer-related pelvic osteomyelitis: A neglected disease? Open Forum Infect Dis 2015 Sep; 2:ofv112 PMID: 26322317 http://ofid.oxfordjournals.org/content/2/3/ofv112
  34. DermNet NZ. Bedsores (images) http://www.dermnetnz.org/reactions/bedsore.html
  35. Schiffman J, Golinko MS, Yan A et al Operative debridement of pressure ulcers. World J Surg. 2009 Jul;33(7):1396-402. PMID: 19424752 Free PMC Article
  36. Teno JM, Gozalo P, Mitchell SL, Kuo S, Fulton AT, Mor V. Feeding tubes and the prevention or healing of pressure ulcers. Arch Intern Med. 2012 May 14;172(9):697-701. PMID: 22782196 Free PMC Article - Christmas C, Finucane TE. Tube feeding and pressure ulcers: comment on "Feeding tubes and the prevention or healing of pressure ulcers". Arch Intern Med. 2012 May 14;172(9):701-3. PMID: 22782197
  37. Little MO. Nutrition and skin ulcers. Curr Opin Clin Nutr Metab Care. 2013 Jan;16(1):39-49. Review. PMID: 23222706
  38. Campbell C, Parish LC. The decubitus ulcer: facts and controversies. Clin Dermatol. 2010 Sep-Oct;28(5):527-32. PMID: 20797513
  39. Cereda E, Klersy C, Rondanelli M, Caccialanza R. Energy balance in patients with pressure ulcers: a systematic review and meta-analysis of observational studies. J Am Diet Assoc. 2011 Dec;111(12):1868-76. Review. PMID: 22117663
  40. Pittman J, Beeson T, Dillon J, Yang Z, Cuddigan J. Hospital-acquired pressure injuries in critical and progressive care: Avoidable versus unavoidable. Am J Crit Care 2019 Sep; 28:338 PMID: 31474603 https://aacnjournals.org/ajcconline/article/28/5/338/21986/Hospital-Acquired-Pressure-Injuries-in-Critical
  41. Talebraza S et al Geriatrics Evaluation & Management Tools American Geriatrics Society. 2021 https://geriatricscareonline.org/ProductAbstract/geriatrics-evaluation-management-tools/B007/
  42. Qu W, Wang Z, Hunt C et al The Effectiveness and Safety of Platelet-Rich Plasma for Chronic Wounds. Mayo Proc 2021. July 3 PMID: 34226023 https://www.mayoclinicproceedings.org/article/S0025-6196(21)00166-X/fulltext
  43. Hajhosseini B, Longaker MT, Gurtner GC. Pressure injury. Ann Surg. 2020;271(4):671-679 PMID: 31460882 https://journals.lww.com/annalsofsurgery/Abstract/2020/04000/Pressure_Injury.14.aspx
  44. Tescher AN, Thompson SL, McCormack HE, et al. A retrospective, descriptive analysis of hospital-acquired deep tissue injuries. Ostomy Wound Manage. 2018;64(11):30-41 PMID: 30412055 Free article
  45. Aloweni F, Ang SY, Fook-Chong S, et al. A prediction tool for hospital-acquired pressure ulcers among surgical patients: surgical pressure ulcer risk score. Int Wound J. 2019;16(1):164-175 PMID: 30289624 PMCID: PMC7949343 Free PMC article https://onlinelibrary.wiley.com/doi/10.1111/iwj.13007
  46. Oozageer Gunowa N, Hutchinson M, Brooke J et al. Pressure injuries in people with darker skin tones: a literature review. J Clin Nurs. 2018;27(17-18):3266-3275 PMID: 28887872 https://onlinelibrary.wiley.com/doi/10.1111/jocn.14062
  47. Munoz N, Posthauer ME, Cereda E et al The Role of Nutrition for Pressure Injury Prevention and Healing: The 2019 International Clinical Practice Guideline Recommendations. Adv Skin Wound Care. 2020;33(3):123-136 PMID: 32058438 https://journals.lww.com/aswcjournal/Fulltext/2020/03000/The_Role_of_Nutrition_for_Pressure_Injury.3.aspx
  48. Ayello E, Sibbald R Preventing pressure ulcers and skin tears. In: Capezuti E, Zwiker D, Mezey M et al (eds) Evidence-Based Geriatric Nursing Protocols for Best Practice. 3rd ed. 2008:403-429
  49. NEJM Knowledge+ Dermatology
  50. Black JM, Brindle CT, Honaker JS. Differential diagnosis of suspected deep tissue injury. Int Wound J. 2016 Aug;13(4):531-9. PMID: 26123043 PMCID: PMC7950046 Free PMC article.