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EsaSoppi

Prevention and Treatment of Pressure Ulcers

Essentials

  • A pressure ulcer (also previously known as pressure sore, decubitus ulcer or bed sore) usually develops over a bony prominence or a medical device.
  • 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 or 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 minimizing, equalizing 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 (Regulation 2017/745/EU http://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX%3A32017R0745). 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.
    • In Finland (population 5.5 million), for example, it is estimated that some 55 000-80 000 patients with at least one pressure ulcer are treated each year. The cost is estimated to comprise 2-4% of all health care costs; in Finland this corresponded to 535-1 070 million € in 2021.
  • 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.
    • In Finland, for example, it is estimated that 500-1 000 people die as a result of pressure ulcer related complications annually.
  • The development of a pressure ulcer is an adverse event and may potentially be considered a patient injury.

Definition and classification

  • A pressure ulcer is defined as a localised damage to the skin and/or underlying tissues as a result of pressure or pressure in combination with shear. It usually develops over a bony prominence but may also be caused by a medical device or other object.
  • 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

GradeDescription
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.
1Intact skin with non-blanchable erythema usually situated over a bony prominence
2A skin injury extending partially to the dermis with a shallow pink or red wound bed, without slough (picture 1).
3Full thickness skin loss. Subcutaneous fat tissue may be visible but bone, tendon or muscle is not visible (picture 2).
4Full 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.

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 tissue deformation caused by the above factors and leading to an inflammatory reaction. This results in swelling, 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 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 clinical records.

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

  • 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 always be placed on a mattress designed for very high risk patients.
    • The international recommendation divides support surfaces functionally into two main categories.
      • Reactive support surfaces react to the patient's weight, body structure and movement. They can be, as necessary, electrically powered or, for example, made of foam.
      • Active support surfaces are continuously powered by electricity; a typical example is alternating pressure support surfaces.
  • Table T2 presents mattresses/overlays/beds according to their suitability for different patient groups.
    • Seemingly similar types of support surfaces, e.g. alternating pressure support surfaces, have major functional differences between them.
    • 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 relief 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 foam 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 / overlayPatient's risk group (Shape Risk Scale [SRS*] or Braden points 7)
* If SRS or SRS-D(evice) scales are used to assess the risk of pressure ulcer, only the mere 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.
Standard polyurethane mattresses (reactive support surface)
  • For example, high specific density or viscoelastic foam mattresses or combinations of these, including profiled mattresses
Low risk patients (SRS score < 6, Braden score 19-23)
Active (dynamic), alternating pressure support surfacesSelect, low to at most medium risk patients (SRS score 7-12, Braden score 15-18)
Other reactive support surfaces
  • For example, non-adjustable/-adjusting honeycomb/cell-structured overlays
No more than medium risk patients (SRS score 7-12, Braden score 15-18)
Special reactive mattresses
  • For example, higher specification multilayered foam mattresses and active adjustable honeycomb/cell-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
Special reactive/active mattresses
  • For example, automatically adjusted honeycomb/cell-structured overlays or support surfaces with no scientifically proven antideformation properties
Medium-risk (SRS score 7-12, Braden score 15-18) and high-risk (SRS score 13-18, Braden score 10-14) patients
Antideformation support surfaces
  • Reactive support surfaces adjusting automatically according to the patient's weight, position and body structure, function based on scientifically proven antideformation properties (clinical evaluation report)
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
  • End-of-life palliative treatment

Treatment Therapeutic Ultrasound for Pressure Sores, Electromagnetic Therapy for Treating Pressure Ulcers, Foam Dressings for Treating Pressure Ulcers, Anabolic Steroids for Treating Pressure Ulcers, Dressings and Topical Agents for Treating Pressure Ulcers, Topical Phenytoin for Treating Pressure Ulcers, Topical Antibiotics and Antiseptics for Pressure Ulcers, Alginate Dressings for Treating Pressure Ulcers, Negative Pressure Wound Therapy (Npwt) for Treating Pressure Ulcers, Hydrogel Dressings for Treating Pressure Ulcers, Phototherapy for Treating Pressure Ulcers, Support Surfaces for Treating Pressure Ulcer

Wound care Wound Cleansing for Pressure Ulcers

  • In all pressure ulcers, regardless of their grade, the essential task is to minimise 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

ColourWound surfaceTreatment goals
PinkEpithelial tissueThe ulcer must be protected against mechanical stress and shear.
RedGranulation tissueThe ulcer must be protected (a dressing that maintains moisture and promotes the formation of new tissue).
YellowSloughSlough must be debrided (a dressing that promotes the process of autolytic debridement).
BlackNecrotic tissueThe 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 or on (wheel)chair 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 support surface. Whilst sitting in a chair the patient's weight should be shifted often. By using a suitable, higher 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. Pay particular attention to patients who have been or are undernourished or at risk of malnutrition.
    • 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 (adults); energy consumption and overall health should be taken into acccount
    • protein: 1.25-1.5 g/kg (adults); 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.