Pressure Ulcers

Clinical Findings

Reddened, blistered, open skin over pressure point such as sacrum, coccyx, scapula, trochanter, or heel.
History of immobility, decreased sensorium, incontinence.

Possible Causes: Pressure or shearing forces, immobility.

Collaborative Management

Relieve pressure by turning Pt or supporting extremity with pillows.
Do NOT massage area; massage can cause tissue damage under skin.
Do NOT use doughnut-shaped or ring-shaped cushions or heel booties; these items impede circulation.
Assess wound using Wound Assessment and Documentation Guide and/or Pressure Ulcer Stages and Treatment chart in this tab.
Assess Pt for other areas of pressure and skin breakdown.
Assess temp, VS, and pain level.
Assess wound (size, depth, edges, undermining, type and amount of necrotic tissue [color, consistency adherence, and amount], exudate type and amount, color of skin surrounding wound, peripheral tissue edema, induration, granulation tissue, infection). See Wound Assessment and Documentation Guide in this tab.
Assess for pressure ulcer risk using facility assessment tool.
Perform dressing changes as ordered. (See Wound Care Products in this tab.)
Turn and reposition Pt at least every 2 hr.
Keep wound free of contamination from urine and stool.
Assess nutritional status; consult dietitian.
Clean, dress, and pack wound as ordered.
Obtain special wound care products.
Obtain specialized support surface for bed or wheelchair.

Pressure Ulcer Prevention Strategies

Use your facility’s risk assessment tool on all Pts with limited mobility or impaired LOC—Inspect skin daily
Effectively manage urinary and fecal incontinence. Clean skin promptly, using a mild, nonirritating, nondrying cleansing solution. Avoid friction during cleansing.
Use topical moisture barriers and moisture absorbing pad for incontinent Pts.
Position Pt to alleviate pressure and shearing forces.
Reposition Pt every 2 hr when in bed and every 1 hr when in a chair.
Teach Pt to shift weight every 15 min while in a chair.
Use positioning devices and foam padding. Do not use doughnut-shaped devices.
Avoid placing Pt on trochanters or directly on a wound.
Maintain lowest head elevation possible to prevent sacral pressure.
Use lifting devices such as draw sheets or a trapeze.
Prevent contractures.
Provide adequate nutrition and hydration.
Do not massage reddened areas over bony prominences.

Unavoidable Pressure Ulcers

It is now recognized that despite appropriate assessment and intervention, development of pressure ulcers in some instances is unavoidable. Factors that make prevention of pressure ulcers difficult include:

ypoalbuminemia (Alb <3.0).
Respiratory failure with intubation, hypoxemia.
Severe anemia (hemoglobin <10).
Sedation.
Hypotension.
Sepsis, malignancy, diabetes, renal failure (acute or chronic).

Sources: Levine, J, Humphrey, S, Lebovits, S, Fogel, J. (2009). Unavoidable pressure ulcer: a retrospective.JCOM,16(8):1-5; National Pressure Ulcer Advisory Panel (NPUAP). Not all pressure ulcers are avoidable [press release]. Washington, DC: NPUAP; March 3, 2010. Retrieved June 25, 2020 from https://www.prlog.org/10561759-not-all-pressure-ulcers-are-avoidable.html.

Wound Assessment and Documentation Guide

Measure length, width, and depth using a centimeter ruler.
Assess characteristics of wound edges (i.e., attached, not attached, fibrotic).
Assess for undermining: Insert a cotton-tipped applicator under wound edge; gently advance it until resistance is met. Using a felt-tipped pen, mark skin where applicator is felt. Continue around wound.
Describe necrotic tissue type:

White/gray.
Nonadherent yellow slough.
Loosely adherent yellow slough.
Adherent, soft black eschar.
Firmly adherent, hard black eschar.

Describe exudate type:

Bloody.
Serosanguineous.
Serous.
Purulent.
Foul purulent.

Describe exudate amount:

None—wound tissues dry.
Scant—wound tissues moist; no measurable exudates.
Small—wound tissues wet; drainage involved 25% of dressing.
Moderate—wound tissues saturated; drainage involved 25% to 75% of dressing.
Large—wound tissues bathed in fluid; drainage involves >75% of dressing.

Assess and describe skin color surrounding wound: Assess tissues within 4 cm of wound edge. For light-skinned persons, note if skin is reddened. For dark-skinned persons, note if skin is reddened or darker or purplish around wound edges.
Assess wound edge for tissue edema: Note if edema is pitting or nonpitting and if wound is crepitant (crackly noises when tissue is palpated). Notify physician immediately if wound is crepitant: may indicate gas gangrene.
Assess amount of induration: Induration is abnormal firmness of tissues with margins. Assess by gently pinching tissue distal to wound edge; if indurated, you will be unable to pinch a fold of skin.
Assess for granulation tissue: Granulation tissue is present in healing wound. It is regrowth of small blood vessels and connective tissue. Healthy granulation tissue is bright, beefy red, shiny, and granular. Poorly vascularized tissue supply appears pale pink, dull, or dusky red.
Stage pressure ulcer (see following table):

Pressure Ulcer Stages and Treatment

Stage	Ulcer Characteristics	Interventions^*
I	Intact skin. Nonblanchable erythema. May be painful, firm, soft, warmer, or cooler than adjacent tissue. Dark-skinned Pts: Difficult to detect; discoloration, edema, redness, warmth over bony prominence.	No dressing. Prevent continued injury from pressure or shearing forces. Monitor frequently.
II	Clean wound base. Partial-thickness skin loss involving epidermis, dermis, or both. Superficial ulcer looks like abrasion, blister, or shallow crater. No slough or bruising.	Use dressing that will keep ulcer bed moist. Keep surrounding skin dry. Fill wound dead space with loosely packed dressing to absorb excess drainage and maintain moist environment.
III	Eschar and necrosis. Full-thickness skin loss involving damage or necrosis of subcutaneous tissue. May extend down to fascia. Deep crater with or without undermining of adjacent tissue. Depth varies by anatomical location.	Same as stage II plus débride eschar and necrotic tissue. Heel ulcers with dry eschar and no edema, erythema, or drainage may not need débridement. Débridement may be done surgically with enzymatic agents or mechanically with wet-to-dry dressings, water jets, or whirlpool. Do not use topical antiseptics.
IV	Extensive tissue damage. Full-thickness skin loss. Slough or eschar may be present. Extensive destruction and necrosis or damage to muscle, bone, or supporting structures. Undermining and sinus tracts present.	Same as stages II and III plus remove all dead tissue, explore undermined areas, and remove skin “roof.” Use clean, dry dressings for 8–24 hr after sharp débridement to control bleeding, then resume moist dressings.
Unstageable	Full-thickness tissue loss with base covered by yellow, tan, gray, or grayish-brown slough.	Must be débrided to expose wound base so that depth and stage can be determined—Once determined, follow interventions for correct stage.
Suspected deep tissue injury (sDTI)	Stage will be III or IV. Purple or maroon area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.	Intact skin: Use moisture barrier or skin sealant. Observe daily. Blood-filled blister: Keep blister intact, moisture barriers and/or skin sealants may be helpful. Consider adding protective dressing. Observe daily.

^* Treatment always includes removing source of pressure, shear, or friction; careful observation; cleansing pressure ulcer appropriately; providing nutritional support as needed; and changing interventions/dressings based on changes in wound.

Wound Care Products

Product	Characteristics	Indications	Nursing Considerations
Transparent films Tegaderm, CarraFilm, Opsite, Bioclusive	Semipermeable membrane. Waterproof. Permeable to oxygen and water vapor. Provide moist healing environment and prevent bacterial contamination.	Stage I and II wounds. Work best on superficial wounds, blisters, and skin tears.	Transparency allows visual inspection of wound. Can be a secondary dressing over alginates or gels. Dressing change up to three times/week. Do not absorb exudates; change when fluid collects underneath.
Hydrogels Hypergel, CarraSorb, Nu-Gel, Curafil	Water- or glycerinbased gels, impregnated gauzes, or sheet dressings. Provide moist wound environment. Helps clean and débride by supplying liquid to dry, sloughy wounds.	Stage II, III, and IV wounds.	Reduce pain and promote soothing effect. Easy to apply and remove. Require secondary dressing. Do not absorb large amounts of exudate due to large water content. Change once daily.
Hydrocolloid dressings Tegasorb, Comfeel, DuoDERM, Restore	Occlusive and adhesive wafer dressings or hydrocolloid powders and pastes. Facilitate rehydration and autolytic débridement of dry, sloughy, or necrotic wounds.	Stage II and III wounds. Granulating and epithelizing wounds with low to moderate amounts of exudate.	Conformable for easy application; help reduce pain at wound site. Breakdown of product may produce residue and foul odor; do not confuse with infectiou process. Changed up to three times/week.
Alginates Curasorb, AlgiDERM, Sorbsan, Algosteril	Soft, nonwoven fibers derived from seaweed. Available in pads, ropes, or ribbons. Can absorb up to 20 times their weight.	Stage III and IV wounds with moderate to heavy exudate, but not wounds with eschar or dry wound beds.	Highly absorbent, therefore good for packing exudating wounds. Require secondary dressing. Usually changed once daily.
Foam dressings Flexzan, CuraFoam, Mepilex	Highly absorbent dressings made from hydrophilic polyurethane foam. Some have adhesive borders.	Stage III and IV wounds with heavy exudate, especially during inflammatory phase following débridement. Deep cavity wounds and weeping ulcers such as venous stasis ulcers.	Highly absorbent foam may allow less frequent dressing changes. Can be left undisturbed for 3–4 days. Decrease maceration of surrounding tissue. Comfortable and conformable. Usually changed up to three times/week.
Enzymatic débriding agents Panafil, Santyl, Accuzyme	Agents selective in removing necrotic tissues from wound bed.	Stage III and IV wounds. Tunneling wounds (may remove debris in hidden areas).	Surgical débridement may be avoided in some cases with use of enzymatic débriding agents. Require prescription.
Antimicrobial dressings impregnated with silver or cadexomer Acticoat, Allevyn Ag, Aquacel Ag, lodosorb	Available in all types of dressings: gels, films, mesh, foams, paste, ointment, etc. Absorb exudate. Provide immediate and controlled release of silver or iodine to inhibit bacterial growth.	Infected and/or heavily colonized wounds or wounds at high risk for infection. Heavily exudating wounds.	Avoid prolonged use; discontinue when infection is controlled. Cadexomer is an iodide and cannot be used for Pts sensitive to iodine. Most require a secondary dressing. Silver-containing dressings must be removed and wound cleaned before magnetic resonance imaging.
Honey-impregnated dressing Medihoney, Apinate	Available as a gel, paste, in alginate, hydrocolloid, and other dressing forms.	Stage II and III ulcers.	Honey-impregnated dressings cannot be used for Pts with bee-sting or honey allergies.
Collagen matrix dressings Promogran Prisma, BioPad, Fibracol Plus	Provide a structure for new collagen and granulation tissue. Absorbent and conform to wound. Available in gels or particles.	Nonhealing stage III and IV ulcers. Minimal to heavily exudating wounds.	Requires a secondary dressing. May be used in combination with antimicrobials and alginates. Collagen dressings are a type of biological dressing. Other biological dressings include tissue-engineered cultured skin products and growth factors.

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