Pressure Areas and Pressure Ulcers

OVERVIEW

International NPUAP-EPUAP Pressure Ulcer Definition

• A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear
• A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated

Pressure ulcers are preventable!

PATHOPHYSIOLOGY

Predisposing factors (4Ps)

• pressure +/- shear
• poor perfusion
• poor healing
• poor ‘padding’ / prominence’s

Development of pressure ulcers

• can develop within 2-6 hours
• most vulnerable areas are the heels, coccyx, sacrum, femoral trochanter (bony prominences)
• skin and subcutaneous tissues compressed or subjected to shear forces
  -> decreased perfusion
  -> tissue necrosis

RISK FACTORS

Patient and care characteristics

• advanced age
• male
• white race
• smoker
• low BMI
• impaired mobility
• urinary and faecal incontinence
• history of pressure ulcers
• altered mental state
• fever
• hypotension
• requiring physical restraints
• inadequate care

Comorbidities

• malignancy
• diabetes mellitus
• stroke
• pneumonia
• heart failure
• sepsis
• malnutrition
• renal failure

Laboratory

• anaemia
• lymphopenia
• hypoalbuminaemia

ASSESSMENT

Assess risk score (various risk scales are in use — none are validated in critical care settings)

• Braden score
• Norton score
• Waterlow score

Assess ulcer features and possible causes

• ulcer location, area, depth, drainage, tissue type present and presence of cellulitis
• ulcer staging
• underlying risk factors and reversible conditions

International NPUAP-EPUAP pressure ulcer staging (detailed description here and images here)

• Stage I: Non-blanching erythema
• Stage II: Partial thickness
• Stage III: Full thickness skin loss — involving subcutaneous tissue (underlying fascia is intact)
• Stage IV: Full thickness tissue loss — involving underlying bone, tendon, muscle or cartilage

Various other staging systems exist

MANAGEMENT

Overview

• aim to provide the ulcer the optimal environment for healing
• evidence base is lacking

Prevention

• risk assessment and monitoring
• treat underlying critical illness and reversible factors
• mobilize
• manage urinary incontinence and diarrhoea
• avoid pressure and friction e.g. 2 hourly repositioning, appropriate padding and mattresses
• ensure adequate nutrition
• skin care e.g. keep clean and dry
• minimise sedation
• promote wound healing e.g. stop medications that impair wound healing, control diabetes, optimise local and systemic perfusion
• staff education

Specific therapy

• Debridement
  – mechanical (wet to dry gauze)
  — autolytic (dressings that promote breakdown of necrotic tissue by body’s own enzymes)
  — enzymatic (proteolytic enzymes)
  — scalpel or laser debridement
  — maggot therapy
• Managing bacterial burden
  – silver impregnated dressing or silver sulfadiazine
• Exudate management
  – avoid excessive moisture
  — > 300 dressings available!
• Monitor healing
• Surgery rarely required
  — direct closure, skin grafting, skin flaps, musculocutaneous flaps, free flaps, stents and revascularisation
• Adjunctive therapies
  — electrical stimulation, topical growth factors, skin equivalents, hyperbaric oxygen

Supportive care and monitoring

References and Links

Journal articles

• Agrawal K, Chauhan N. Pressure ulcers: Back to the basics. Indian J Plast Surg. 2012 May;45(2):244-54. PMC3495374.
• Health Quality Ontario. Pressure ulcer prevention: an evidence-based analysis. Ont Health Technol Assess Ser. 2009;9(2):1-104. PMC3377566.

FOAM and web resources

• National Pressure Ulcer Advisory Panel (NPUAP)
• Australian Wound Management Association — Publications (includes pressure ulcer guidelines)