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)
Critical Care
Compendium
Leave a Reply