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EsaSoppi

Prevention and Treatment of Pressure Ulcers

Essentials

A pressure ulcer (also known as pressure sore, decubitus ulcer or bed sore) usually develops over a bony prominence.
The risk is highest in patients with restricted mobility or impaired pain sensation, but a pressure ulcer may develop very quickly in the context of an acute illness, emergency care, patient transport, investigations or a surgical operation.
The accuracy of risk assessment can be improved by combining a holistic clinical evaluation with a validated risk assessment tool.
The prevention and treatment must focus on minimising or redistributing pressure exerted on risk areas (repositioning, special mattresses and seat cushions).
All healthcare devices and supplies, including mattresses and bed support surfaces, must be CE-marked, and/or their efficacy must be proven by a clinical evaluation report. Note national regulations as well.
The same issues should be considered in treatment as in prevention. Additionally, the care principles for chronic ulcers should be followed, as defined by the depth of the ulcer.
The prevention of pressure ulcers plays a significant part in patients' quality of life.

Frequency and significance

The prevalence of pressure ulcers among patients in different healthcare facilities is 5-25%, sometimes even higher, depending on the patient group and country concerned (see e.g. http://www.magonlinelibrary.com/doi/abs/10.12968/jowc.2019.28.11.710?journalCode=jowc). Care of pressure ulcers consumes substantial financial resources. Prevention costs are only about 10% of the respective treatment costs.
Development of a pressure ulcer is associated with an increased risk of death, the mechanism of which is unknown.
A significant portion of pressure ulcers remains undiagnosed whilst other sores/ulcers are often misdiagnosed as pressure ulcers.
The development of a pressure ulcer is an adverse event and may potentially be considered a patient injury.

Definition and classification

A pressure ulcer denotes a localised injury to the skin and/or underlying tissues. It usually develops over a bony prominence and is caused by pressure or the combination of pressure and shear.
- Pressure ulcers may also be caused by medical devices or other objects.
The classification of pressure ulcers is presented in Table T1.
The depth of grade 3 and 4 pressure ulcers is dependent on their anatomic location. The thinner the subcutaneous fat layer is, the shallower the pressure ulcers are and the quicker they may develop.

Classification of pressure ulcers

Grade	Description
1	Intact skin with non-blanchable erythema usually situated over a bony prominence
2	A skin injury extending partially to the dermis with a shallow pink or red wound bed, without slough (picture ).
3	Full thickness skin loss. Subcutaneous fat tissue may be visible but bone, tendon or muscle is not visible (picture ).
4	Full thickness tissue loss which extends to the bone, tendon or muscle
Unclassified	Unknown depth; full thickness tissue loss with the wound bed obscured by eschar or necrosis. Suspected deep tissue injury: localised purple or maroon area of skin, or blood-filled blister, caused by damage to the underlying soft tissue resulting from pressure, or from pressure associated with shear/friction.

This scale cannot be used to reverse grade a deep pressure ulcer as it heals to a superficial one; for example, a grade 4 pressure ulcer does not become a grade 3 or 2 pressure ulcer as it heals.

The development of a pressure ulcer

Factors contributing to the development of a pressure ulcer
- Pressure-induced stress factors within the tissues, including the magnitude and character of mechanical loading (friction, shear) and the duration of the applied load, the character and geometry of the interfaces, the pliability and elasticity of tissues
- Individual threshold for injury, i.e. personal ”tissue tolerance”; physiological and chemical changes within the tissues resulting from the stress reaction
- A pressure ulcer develops through mechanical damage to the tissues caused by the above factors and leading to an inflammatory reaction. This results in lack of oxygen and finally in the development of a clinically observable pressure ulcer.
More than half of patients have the wrong type of mattress or bed support surface in relation to their risk category.
Patients at the highest risk are those with either acute or long-term mobility restrictions as well as patients with impaired pain sensation due to an illness or medication.
There may be a considerable time delay between the development of a pressure ulcer and the actual trigger situation, and a pressure ulcer is often not noted until later on when the patient is already on a different ward or in a different health care facility. Hence, attention should be paid to the risk of pressure ulcer development in every phase of the treatment process.
A considerable share of pressure ulcers originates from pressure damage caused by medical devices, such as catheters and masks.

Risk assessment

A pressure ulcer risk assessment made with the aid of a validated risk assessment scale is more accurate than an assessment based solely on clinical judgement.
The pathophysiology of pressure ulcers is complex, and no risk assessment scale can be totally reliable. A result yielded by an assessment scale should therefore always be complemented with a comprehensive clinical assessment.
A patient with a history of a pressure ulcer always belongs to the very high risk group.
Several scales have been developed for predicting the pressure ulcer risk; the scales recommended to be used for routine patients include the Braden Scale http://www.bradenscale.com/ and the Shape Risk Scale (SRS).
In special patient groups, including children and patients in intensive care units, scales specially designed to be used in these patient groups are recommended.
Risk assessment should be carried out as soon as the patient is admitted, and a reassessment should be carried out if the patient's circumstances change. The timing and results of the risk assessment must be documented in the patient's notes.

Prevention Dressings and Topical Agents for Preventing Pressure Ulcers, Repositioning for Pressure Ulcer Prevention in Adults, Risk Assessment Tools for the Prevention of Pressure Ulcers, Beds, Mattresses and Cushions for Pressure Sore Prevention

A repositioning regime carried out every two hours has been considered to be the basis of pressure ulcer prevention; pressure ulcer prevention aims to reduce pressure exposure. However, there is no scientific evidence to support the two-hourly regime.
The patient should be placed on a support surface that corresponds to his/her risk category Beds, Mattresses and Cushions for Pressure Sore Prevention.
- A patient with a pressure ulcer should be placed on a mattress designed for very high risk patients.
Table T2 presents mattresses/overlays/beds according to their mechanism of action and their suitability for different patient groups. If necessary, a wound care/tissue viability nurse should be consulted about the selection of a suitable support surface.
The interface between the support surface and the patient's skin should be as free as possible of bed linen / incontinence sheets / handling equipment since these usually interfere with the pressure-redistributing properties of the support surface.
Moreover, pressure redistribution can also be provided with the use of padding as well as wedge-shaped and other positioning pillows (making sure that the padding/pillow itself does not have areas that exert point pressure) and genuine sheepskins (usually in home care).
The use of various doughnut-type "protective" devices/rings (whether O- or U-shaped) is contraindicated.
Health care units should use a maximum of 3 different types of support surfaces, and regular support surfaces should not be used at all in units where half or more of the patients have a medium or higher risk of pressure ulcer.

Classification of support surfaces and overlays, their suitability in different risk groups and mechanisms of action

Support surface / overlay	Patient's risk group (Shape Risk Scale [SRS*] or Braden points 10)	Characteristics and mechanisms of action
Hygiene mattresses, or standard polyurethane mattresses (reactive static support surface) For example, high specific weight or viscoelastic foam mattresses or combinations of these, including profiled mattresses	Low risk patients (SRS score < 6, Braden score 19-23)	Equalization of pressure on the tissue mainly by controlling immersion No redistribution of body pressure on the support surface Increased temperature increases oxygen consumption
Active (dynamic), alternating pressure mattresses	Select, low to at most medium risk patients (SRS score 7-12, Braden score 15-18)	Cyclic tissue deformation No tissue pressure equalization; on the contrary, there is significant variation in pressure Immersion control combined with constant alternation of tissue pressure and cyclic stimulation of circulation and oxygenation No redistribution of body pressure on the support surface Probably neutral temperature effect
Other reactive mattresses For example, non-adjustable honeycomb-structured overlays, i.e. static support surfaces	No more than medium risk patients (SRS score 7-12, Braden score 15-18)	Equalization of tissue pressure by controlling both immersion and envelopment Redistribution of body pressure on the support surface may occur to some extent particularly when certain types of combination mattresses with foam and honeycomb structure are used The effect of temperature depends on the structure of the support surface
Special reactive mattresses For example, high-quality, or medium-risk, foam mattresses (MRFM, static support surface) and active adjustable honeycomb-structured overlays	Medium-risk (SRS score 7-12, Braden score 15-18) and certain high-risk (SRS score 13-18, Braden score 10-14) patients	Equalization of tissue pressure by controlling both immersion and envelopment Redistribution of body pressure on the support surface may occur to some extent particularly when certain types of air mattresses are used Air-cell structured mattresses have a favourable temperature effect
Special reactive/active mattresses For example, automatically adjusted air-cell structured overlays or support surfaces with no antideformation properties	Medium-risk (SRS score 7-12, Braden score 15-18) and high-risk (SRS score 13-18, Braden score 10-14) patients	Equalization of tissue pressure by controlling both immersion and envelopment There may be redistribution of body pressure on the support surface Air-cell structured mattresses have a favourable temperature effect
Minimum-pressure support surfaces Reactive support surfaces adjusting automatically to the patient's weight, position and body structure, function based on antideformation	High-risk (SRS score 13-18, Braden score 10-14) and very high-risk (SRS score >19**, Braden score 6-9) patients The only choice in certain special patient groups, e.g. patients with extreme pain, multiple injuries, fractures of the spine/cervical spine, hypothermia therapy End-of-life palliative treatment	Equalization of tissue pressure and optimal control of the combined effect of immersion and envelopment Regardless of the patient and his/her position, the support surface provides a continuous maximum contact surface with good pressure equalization and redistribution, particularly if the effect is based on evidence of antideformation characteristics Air-cell structured mattresses have a favourable temperature effect

* If SRS or SRS-D scales are used to assess the risk of pressure ulcer, only the SRS score should be considered when choosing the support surface..
** The risk is very high whenever a patient has or has had a pressure ulcer.

Wound care Wound Cleansing for Pressure Ulcers

In all pressure ulcers, regardless of their grade, the essential task is to minimise/redistribute pressure (repositioning, special mattresses, seat cushions), i.e. to apply all available preventive measures.
Grade 1
- Reddened areas must not be massaged/rubbed. Rubbing may cause mild tissue damage.
- A wound care nurse should be consulted.
Grades 2-4
- The skin area must be protected against friction, moisture and infection.
- A consultation with a wound care nurse and a plastic surgeon (in grade 3 to 4 ulcers) is indicated.
- Conservative treatment of an open wound can be determined according to the colour of the wound: see Table T3.

Conservative treatment of an open wound according to the colour of the wound

Colour	Wound surface	Treatment goals
Pink	Epithelial tissue	The ulcer must be protected against mechanical stress and shear.
Red	Granulation tissue	The ulcer must be protected (a dressing that maintains moisture and promotes the formation of new tissue).
Yellow	Slough	Slough must be debrided (a dressing that promotes the process of autolytic debridement).
Black	Necrotic tissue	The necrotic tissue must be removed; the fastest method is surgical debridement. A dressing that promotes the process of autolytic debridement.

Positioning and repositioning regime

Whilst in bed the patient should be repositioned, or his/her weight slightly shifted, taking into account the general health of the patient, skin and tissue condition and the properties of the bed support surface. Whilst sitting in a chair the patient's weight should be shifted often. By using a suitable, high-specification seat cushion it might be possible to lengthen the interval between repositionings without a risk of skin damage or discomfort caused by sitting. The patient should be instructed to, inasmuch as possible, change the point of pressure while sitting or to decrease pressure by lifting him-/herself up off the chair every now and then.
During bed rest, the patient's position should be changed, or weight shifted, so that
- no direct pressure or shear stress is exerted over the bony prominences or the heels
- the limbs do not rest against each other.
Moving patients by dragging them over the support surface should be avoided as this may exert shear stress and friction on the skin and tissues.
Use of aids
- Lightweight lifting and handling aids are available to assist repositioning, including slide sheets and special transfer sheets with handles and a protective top layer that absorbs moisture effectively away from the skin.
- Transfer boards and hoists
Moreover, the positioning/repositioning regime must take into account the chosen special mattress, cushion and transfer aids.

Skin care

Good hygiene promotes skin integrity.
Dry skin can be cared for and protected by moisturising the skin. Healthy skin should be moisturised only if indicated.
In order to protect bony prominences and reddened skin areas, as well as to reduce friction and prevent the skin from breaking down, wound care products such as transparent films and hydrocolloid/polyurethane foam dressings can be applied.

Patients with incontinence

Urinary incontinence leads to maceration of the skin, which should be prevented with the use of dry surface incontinence pads/pants and other incontinence products which allow the skin to stay dry. The skin should be protected with skin protection sprays and creams.
Using and changing of incontinence products should be done carefully so that their removal will not stretch the damp skin.
If the skin is macerated and is about to break, the insertion of a suprapubic cystostomy catheter or an indwelling urinary catheter may temporarily promote skin healing.
If faeces leak frequently or macerate the skin, the skin should be protected with special creams, skin protection sprays or thin barrier films. Faecal management systems may also be beneficial if diarrhoea occurs more than 3 times a day.

Nutrition

Balanced nutrition maintains tissue health.
- The patient's nutritional status should be assessed using a validated tool, e.g. MUST, NRS 2002, MNA.
- The calorie and nutrient requirements and intake should be monitored.
The nutrition of patients at risk should include (note the amount of fat tissue)
- energy: 30-35 kcal/kg/day; energy consumption and overall health should be taken into acccount
- protein: 1.25-1.5 g/kg; kidney function should be taken into account
- fluids: based on need; take fever, diuresis, diarrhoea, vomiting, etc. into account
Nutritional supplements Nutritional Interventions for Preventing and Treating Pressure Ulcers and vitamins may also be given to patients at risk of pressure ulcers.

References

European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers/injuries: Clinical practice guideline. The International Guideline, 3rd Edition (2019). Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA 2019.
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Soppi E. Critical review of the role of alternating mattresses in pressure ulcer management. 18th EPUAP meeting, 17-19.9.2015, Ghent, Belgium
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Demarré L, Verhaeghe S, Annemans L et al. The cost of pressure ulcer prevention and treatment in hospitals and nursing homes in Flanders: A cost-of-illness study. Int J Nurs Stud 2015;52(7):1166-79. [PubMed]
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Ahtiala M, Soppi E, Wiksten A, Koskela H, Grönlund J. Occurrence of pressure ulcers and their risk factors in mixed medical-surgical ICU - A cohort study. Journal of Intensive Care Society 2014; 15: 2-4.
Bauer K, Rock K, Nazzal M et al. Pressure Ulcers in the United States' Inpatient Population From 2008 to 2012: Results of a Retrospective Nationwide Study. Ostomy Wound Manage 2016;62(11):30-38. [PubMed]
Ahtiala M, Kivimäki R, Laitio R, Soppi E. Effect of mattress deployment on the development of pressure ulcers - a real world observational cohort experience. Wounds Int 2020; 11(1):10-17 http://www.woundsinternational.com/resources/details/effect-of-mattress-deployment-on-pressure-ulcer-development-a-realworld-observational-cohort-experience#:~:text=The%20significant%20reduction%20in%20PU,any%20of%20the%20other%20mattresses.
Ahtiala MH, Kivimäki R, Laitio R ym. The Association Between Pressure Ulcer/Injury Development and Short-term Mortality in Critically Ill Patients: A Retrospective Cohort Study. Wound Manag Prev 2020;66(2):14-21. [PubMed]
Gefen A. The future of pressure ulcer preventiopn is here: Detecting and targeting inflammation early. EWMA J 2018;19(2):7-13. http://ewma.org/fileadmin/user_upload/EWMA.org/EWMA_Journal/articles_previous_issues/Gefen_A.pdf

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