Pressure Ulcer Assessment and Management

OBJECTIVES
By the end of the course participants will be able to:

 Classify pressure ulcers by stage and differentiate ulcers of

non-pressure etiology.

 Discuss current treatment practices and interventions for

pressure ulcer management.
 What are Pressure Ulcers?
Localized areas of tissue necrosis which develop when
soft tissue is compressed between a bony prominence
and an external surface for a prolonged period of time.

Most pressure ulcers occur over bony prominences,

where combined with friction and shearing forces result
in skin breakdown.

Several factors other than pressure contribute to ulcers

including moisture, friction, shear, immobility, sensory
loss and some underlying medical conditions.
Common Pressure Ulcers sites

Supine:
23% sacro-coccygeal
8% heels
1% occiput; spine
Sitting:
24% ischium
3% elbows
Lateral:
15% trochanter
7% malleolus
6% knee
3% heels
Classification of Pressure Ulcers

The staging of pressure ulcers, as defined by national

guidelines allow for common understandings for
healthcare professionals. The staging of a pressure ulcer
reflects the amount of tissue damage.

 STAGE I
 STAGE II
 STAGE III
 STAGE IV
 SUSPECTED DEEP TISSUE INJURY (DTI)
 UNSTAGEABLE
Stage I Pressure Ulcer
Intact skin with non-blanchable redness of a localized area
usually over a bony prominence. Darkly pigmented skin
may not have visible blanching; its color may differ from the
surrounding area.
 Management of Stage- I
Pressure Ulcers
Stage I on Trunk of the Body –
 Manage incontinence, keeping area
clean and dry.
 Use moisture barrier cream PRN.
 Off load area of pressure ulcer with
pressure reducing / distribution surface and
turning and repositioning schedule.
Stage I on Heels –
 Ensure that heel(s) are floated at all times
with frequent monitoring.
Stage II Pressure Ulcer
Partial thickness loss of dermis presenting as a shallow open
ulcer with a red pink wound bed, without slough. May also
present as an intact or open/ruptured serum-filled blister.
 Management of Stage- II
Pressure Ulcers
Dry Wound Bed
 Cleanse with normal saline, apply small amount of hydrogel and
cover with non adherent dressing, change every day.
Off load area of pressure ulcer with pressure reducing /
distribution surfaces and turning and repositioning schedule.
Minimal Drainage
Cleanse with normal saline, apply hydrocolloid dressing every
three days and PRN soiling or dislodging. Monitor placement every
day.
Stage III Pressure Ulcer
Full thickness tissue loss. Subcutaneous fat may be visible but
bone, tendon or muscles are not exposed. Slough may be present
but does not obscure the depth of tissue loss. May include
undermining and tunneling
 Management of Stage- III
Pressure Ulcers
Minimal Drainage and Clean Wound Bed
Cleanse with normal saline, apply small amount of hydrogel and cover with
non adherent dressing change every day.
Off load area of pressure ulcer with pressure relieving / distribution surface
and turning and repositioning schedule.
Presence of Slough with drainage
 Sharp debridement / Enzymatic debridement
Use Foam or Calcium Alginate dressing for moderate to copious drainage
management.
 Slough 30% or less in the wound, negative pressure wound therapy is
preferred treatment.
Stage IV Pressure Ulcer
Full thickness tissue loss with exposed bone, tendon or muscle.
Slough or eschar may be present on some parts of the wound
bed. Often include undermining and tunneling.
Management of Stage- IV
Pressure Ulcers
Minimal Drainage and Clean Wound Bed
Cleanse with normal saline, apply hydrogel and cover with non
adherent dressing change every day.
Off load area of pressure ulcer with pressure relieving surface and
turning and repositioning schedule.
Presence of Slough with drainage
 Sharp debridement.
Use Foam or Calcium Alginate dressing for moderate to copious
drainage management.
 Slough 30% or less in the wound, negative pressure wound therapy
is preferred treatment.
 Tunneling and undermining shall be filled appropriately.
Suspected Deep Tissue Injury
Purple or maroon localized area of discolored intact skin or blood-filled
blister due to damage of underlying soft tissue from pressure and/or
shear. The area may be preceded by tissue that is painful, firm, mushy,
boggy, warmer or cooler as compared to adjacent tissue.
Management of Suspected
Deep Tissue Injury

Cleanse with normal saline, apply foam dressing change

every day.
Off load area of pressure ulcer with pressure relieving /
distribution surface and turning and repositioning
schedule.
Use Foam dressing for drainage management.
 Castor oil / Trypsin spray is the preferred treatment.
Un-stagable Pressure Ulcer

Full thickness tissue loss in which the base of the ulcer is covered
by slough (yellow, tan, gray, green or brown) and/or eschar (tan,
brown or black) in the wound bed. Base of the wound cannot be
visualized.
 Management of Un-stageable
Pressure Ulcers

Cleanse with normal saline, apply hydrogel and cover with

non adherent dressing change every day.
Off load area of pressure ulcer with pressure relieving /
distribution surface and turning and repositioning schedule.
Use Foam dressing for drainage management.
 Sharp or enzymatic debridement for the management of
slough.
Causative Factors for the Development of
Pressure Ulcers
 Immobility or limited mobility
 Bowel & Bladder Incontinence
 Shearing and friction injuries
 Advanced age
 Malnutrition or debility
 Obesity
 History of pressure ulcers
 Dehydration
 Contractures
 Use of orthotic devises or restraints
 Lack of compliance
 Use of diapers / excess skin moisture
Pressure Ulcer Prevention / Nursing Interventions
 Turn every 2 hours (q2h) Schedule: e.g. alternating positions Right/Back/Left q2h. May
place pillow under one hip at a time if patient cannot tolerate full turning.

 Maximal Remobilization: Passive range of motion, physical therapist (PT) consult to plan
appropriate measures for patient. Spinal Cord Injury and Disorder (SCI&D) patients (or any
patient with custom chairs) are to sit in their own wheelchairs and cushions only.

 Protect Heels: Support entire leg with pillows to allow heels to suspend above the mattress
or use heel protectors. Assess heels everyday for signs of pressure. Consider pressure relieving
/ distribution bed surface.

 Manage Moisture: Correct cause, (e.g., diarrhea), reduce or eliminate incontinent episodes
(e.g., bladder training); Use mild soap, rinse, and dry skin well and apply moisture barrier
cream. No diapers while patient in bed.

 Manage Nutrition: Increase protein intake more than 100% RDA, if not renal or liver
impaired. Dietary consult to determine dietary needs and/or effectiveness of tube feedings.

 Reduce Friction and Shear: Use bed trapeze or pull sheet for lifting and moving patient up
in bed. Apply transparent film or hydrocolloid dressing (Duoderm) over friction areas (e.g.,
elbows) Keep the head of the bed less than 30 degrees as often as possible.
 Treatment of wounds originally consisted of homemade
remedies and evolved very little for many years.
 In 1867, Lister introduced antiseptic dressings by soaking
lint and gauze in carbolic acid.
 The main purpose of wound dressings is to provide the
ideal environment for wound healing.
 The dressing should facilitate the major changes taking
place during healing to produce an optimally healed
wound.
Table 9-8 Desired Characteristics of Wound Dressings

Promote wound healing (maintain moist environment)

Comfortability
Pain control
Odour control
Non-allergenic and non-irritating
Permeability to gas
Safety
Non-traumatic removal
Cost-effectiveness
Convenience
 PRINCIPLES
 Covering a wound with a dressing mimics the barrier role
of epithelium and prevents further damage.
 In addition, application of compression provides
hemostasis and limits edema.
 Occlusion of a wound with dressing material helps healing
by controlling the level of hydration and oxygen tension
within the wound.
 It also allows transfer of gases and water vapour from the
wound surface to the atmosphere.
 Occlusion affects both the dermis and epidermis, and it has
been shown that exposed wounds are more inflamed and
develop more necrosis than covered wounds.
 Occlusion also helps in dermal collagen synthesis and
epithelial cell migration and limits tissue desiccation.
 As it may enhance bacterial growth, occlusion is
contraindicated in infected and highly exudative wounds.
 Dressings can be classified as primary or secondary.

 A primary dressing is placed directly on the wound and

may provide absorption of fluids and prevent desiccation,
infection, and adhesion of a secondary dressing.

 A secondary dressing is one that is placed on the primary

dressing for further protection, absorption, compression,
and occlusion.

 Two concepts that are critical in selecting appropriate

dressings for wounds are occlusion and absorption.
 Winter and colleagues published a study demonstrating
that the rate of epithelialization under an occlusive
dressing was twice that of a wound that was left uncovered
and allowed to dry.
 Placement of an occlusive dressing over the wound
provides a mildly acidic pH and low oxygen tension on the
wound surface.
 The steep oxygen gradient is a good environment for
proliferation of fibroblasts and formation of granulation
tissue.
 absorption would be beneficial in wounds that have a
significant amount of exudate or wounds with high
bacterial counts.
 The skin surrounding the wound can become macerated
with large amounts of uncontrolled exudate.
 These wounds require a dressing that reduces the bacterial
load within the wound while removing the exudate
produced.
 Placement of a pure occlusive dressing without bactericidal
properties will allow bacterial overgrowth and worsen the
infection.
 Wound dressings can be categorized into four classes:
 nonadherent fabrics
 absorptive dressings
 occlusive dressings
 creams, ointments, and solutions
1 Non adherent fabric
 are generally fine-mesh gauze supplemented with a
substance to augment its occlusive properties or
antibacterial abilities.
2 Absorptive dressings
 used mainly for wounds that produce a significant
amount of exudate
 Wide-mesh gauze is the oldest of this type of dressing
and is very absorbent, but it loses its effectiveness when
saturated.
NON ADHERENT DRESSING
ABSORPTIVE DRESSING
 Newer materials such as foam dressings provide the

absorbent qualities to remove large quantities of exudate

and have a nonadherant quality to prevent disruption of
newly formed granulation tissue on removal.

 Examples are : Lyofoam , Curafoam, Flexzan, and

VigiFOAM

 Wound healing beneath absorptive dressings appears to

be slower than under occlusive dressings, possibly

because of wicking of cytokines from the wound bed or
decreased keratinocyte migration.
3 Occlusive dressing
 provides moisture retention, mechanical protection,

and a barrier to bacteria.

 The occlusive class can be divided into biologic and

nonbiologic dressings.

 Examples of biologic dressings are allograft, xenograft,

amnion, and skin substitutes.

 Pigskin is the most commonly used xenograft.

OCCLUSIVE AND SEMI OCCLUSIVE DRESSING
 Homografts and xenografts are temporary dressings in
that both are rejected if left on a wound for an extended
period.
 Amnion is derived from human placentas. These
dressings are often used in the treatment of burn
wounds.
 newest type of wound dressings are skin substitutes that
can be used for structural support and scaffolding for
regeneration. Examples include :
 Integra -

 Integra is a bilayer membrane system for skin replacement.

 The first layer is made of a porous matrix of cross-linked

bovine tendon collagen and a GAG (chondroitin 6-sulfate).

 The second layer is made of synthetic polysiloxane polymer

(silicone) and functions to control moisture loss from the
wound.
 The first layer serves as a template for the infiltration of
fibroblasts, macrophages, lymphocytes, and capillaries from
the wound bed.

 During the healing process, a new collagen matrix is

deposited by fibroblasts and the dermal layer of the template
is degraded.

 Once vascularization of the dermal layer is complete, a thin

autograft can be applied after removal of the silicone layer.
 Alloderm
is an acellular dermal matrix derived from donated human skin
tissue. It provides the matrix for revascularization and incorporation
into host tissue.
 Apligraf
is a living, bilayered biologic dressing that has been designed to
simulate normal skin.
Initially, neonatal-derived dermal fibroblasts are cultured in a
collagen matrix for 6 days. Human keratinocytes are then cultured
on top of this neodermis.
The dressing contains matrix proteins and expresses cytokines.It
does not contain melanocytes, Langerhans cells, macrophages,
lymphocytes, or the adnexal structures normally present in human
skin.
4. Creams, ointments, and solutions.
 This is a broad category that extends from traditional materials,
such as zinc oxide paste, to cutting-edge preparations containing
growth factors.
 The various categories include those with antibacterial
properties such as acetic acid, Dakin's solution, silver nitrate,
mafenide (Sulfamylon), silver sulfadiazine (Silvadene), iodine-
containing ointments (Iodosorb), and bacitracin.
 They are indicated when clinical signs of infection, such as an
increase in exudate or cellulitis, are present or if quantitative
culture demonstrates greater than 105 organisms per gram of
tissue.
Types of surgical dressing
A. POLYMERIC FILM
 Opsite
 Bioclusive
 Tegaderm
• They are transparent dressing for sutured wounds or
donor sites.
• Their advantages are:
 Barrier to bacteria including MRSA
 Reduce the risk of maceration
 Reduce the risk of blistering
 Reduce pain on removal

 Waterproof ,conformable and comfortable to wear

 Manage exudate through a highly absorbent pad and breathable

film

 Easy to apply and remove aseptically

 Allow constant monitoring on the wound and peri-wound area

 are permeable to gases such as water vapour and oxygen but

impermeable to larger molecules including proteins and
bacteria.
 This property enables insensible water loss to evaporate, traps
wound fluid enzymes within the dressing, and prevents bacterial
invasion.
 Transparent film dressings were found to provide the
 fastest healing rates

 lowest infection rates

 most cost-effective method for dressing split-thickness skin

graft donor sites.
OPSITE
OPSITE TEGADERM
B FOAMS
 silastic foams can be shaped to fit deep cavities and
granulating wounds.

 It is absorbent and non adherent.

 They consist of two layers, a hydrophilic silicone or

polyurethane-based foam that lies against the wound
surface, and a hydrophobic, gas permeable backing to
prevent leakage and bacterial contamination.

 Some foams require a secondary adhesive dressing.

FOAM
 Advantages of foams include their high absorptive capacity and
the fact that they conform to the shape of the wound and can be
used to pack cavities.

 Minimize maceration of peri-wound edges (can be used in areas

of fragile skin)

 Can be used under compression .

 Disadvantages of foams include the opacity of the dressings and

the fact that they may need to be changed each day.

 Foam dressings may not be appropriate on minimally exudative

wounds, as they may cause desiccation.
c. ALGINATES
 Natural complex polysaccharides from various types of algae
form the basis of alginate dressings.
 Their activity as dressings is unique because they are
insoluble in water, but in the sodium-rich wound fluid
environment these complexes exchange calcium ions for
sodium ions and form an amorphous gel that packs and
covers the wound.
 Alginates come in various forms including ribbons, beads,
and pads.
 these dressings are more appropriate for moderately to
heavily exudative wounds.
ALGINATES
 Advantages

 augmentation of hemostasis

 they can be used for wound packing

 most can be washed away with normal saline in order to

minimize pain during dressing changes
 they can stay in place for several days.

 Disadvantages

 they require a secondary dressing that must be removed in

order to monitor the wound
 they can be too drying on a minimally exudative wound

 they have an unpleasant odor

D. HYDROCOLLOIDS
 consist of a gel or foam on a carrier of self-adhesive
polyurethane film.
 The colloid composition of this dressing traps exudate
and creates a moist environment.
 Bacteria and debris are also trapped, and washed away
with dressing changes in a gentle, painless form of
mechanical debridement.
 Another advantage of hydrocolloids is the ability to use
them for packing wounds
 Disadvantages

 Mal-odour
 Daily dressing change
 Allergic dermatitis.

 Cadexomer iodine is a type of hydrocolloid in which iodine is

dispersed and slowly released after it comes in contact with
wound fluid.
 The concentration of iodine released is low and does not
cause tissue damage
 Hydrocolloid products include DuoDERM, Tegasorb, J and J
Ulcer Dressing, and Comfeel.
E. HYDROGELS
 Hydrogels are a matrix of various types of synthetic
polymers with >95 percent water formed into sheets,
gels, or foams that are usually sandwiched between two
sheets of removable film.
 The inner layer is placed against the wound, and the
outer layer can be removed to make the dressing
permeable to fluid.
 These unique matrices can absorb or donate water
depending upon the hydration state of the tissue that
surrounds them.
 Hydrogel products include Intrasite Gel, Vigilon,
Carrington Gel, and Elastogel.
 Hydrogels are most useful for dry wounds.
 They initially lower the temperature of the wound
environment they cover, which provides cooling pain
relief for some patients.
 hydrogels have been found to selectively permit gram-
negative bacteria to proliferate .
HYDROCOLLOID AND HYDROGELS
F. HYDROACTIVE
 Hydroactive, the most recently developed synthetic
dressing, is a polyurethane matrix that combines the
properties of a gel and a foam.

 Hydroactive selectively absorbs excess water while

leaving growth factors and other proteins behind .

G. ENZYMATIC
 Enzymatic debridement involves applying exogenous

enzymatic agents to the wound.

 collagenase may promote endothelial cell and

keratinocyte migration, thereby stimulating
angiogenesis and epithelialization.

 Streptokinase/ streptodornase helps in fibrynolysis and

liquefy pus on chronic skin ulcer.

TOPICAL THERAPY
1. GROWTH FACTORS

 Platelet derived growth factor

 Becaplermin is a platelet-derived growth factor (PDGF) gel

preparation that promotes cellular proliferation and angiogenesis.

 for the treatment of diabetic foot ulcers and chronic wounds, it is

the only pharmacological agent approved.

 It is delivered in a topical aqueous-based

sodium carboxymethylcellulose gel.

 It is indicated for noninfected diabetic foot ulcers

 Epidermal growth factor
 topical application of human recombinant epidermal
growth factor was associated with a greater reduction in
ulcer size and higher ulcer healing rate.
 Granulocyte macrophage colony stimulating factor
 Intradermal injections of granulocyte-macrophage
colony stimulating factor (GM-CSF) promote healing of
chronic leg ulcers, including venous ulcers.
2. ANTISEPTIC AND ANTIMICROBIALS
 Cadexomer iodine (eg, Iodosorb) is an antimicrobial
that reduces bacterial load within the wound and
stimulates healing by providing a moist wound
environment.
 Cadexomer iodine is bacteriocidal to all gram-positive
and gram-negative bacteria.
3. BETA BLOCKERS
 Keratinocytes have beta-adrenergic receptors, and beta
blockers may influence their activity and increase the
rate of maturation and migration.
 Timolol is a topically applied beta blocker with some
limited evidence
SKIN SUBSTITUTES
 Manufactured by tissue .
 they promote healing, either by stimulating host cytokine
generation or by providing cells that may also produce
growth factors locally.
 Their disadvantages include
 limited survival

 high cost
 need for multiple applications .
Desired Features of Tissue-Engineered Skin

Rapid re-establishment of functional skin (epidermis/dermis)

Receptive to body's own cells (e.g., rapid "take" and integration)

Graftable by a single, simple procedure

Graftable on chronic or acute wounds

Engraftment without use of extraordinary clinical intervention (i.e., immunosuppression)

 Cultured epithelial autografts (CEAs) represent expanded
autologous or homologous keratinocytes.
 CEAs are expanded from a biopsy of the patient's own skin,
will not be rejected, and can stimulate re-epithelialization
as well as the growth of underlying connective tissue.
 Keratinocytes harvested from a biopsy roughly the size of a
postage stamp are cultured with fibroblasts and growth
factors and grown into sheets that can cover large areas and
give the appearance of normal skin
 CEAs are available from cadavers, unrelated adult donors,
or from neonatal foreskins
 fibroblasts can be grown on bio-absorbable or non-
bioabsorbable meshes to yield living dermal tissue that can
act as a scaffold for epidermal growth.
 Fibroblasts stimulated by growth factors can produce type I
collagen and glycosaminoglycans (e.g., chondroitin
sulfates), which adhere to the wound surface to permit
epithelial cell migration, as well as adhesive ligands (e.g.,
the matrix protein fibronectin), which promote cell
adhesion.
 Indicated for use with standard compression therapy in the
treatment of venous insufficiency ulcers and for the
treatment of neuropathic diabetic foot ulcers
Thank you