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Pressure Ulcer
Amy M. Zack, MD, FAAFP
image BASICS
  • A localized area of soft tissue injury resulting from pressure between an external surface and a bony prominence that causes local tissue breakdown classified in stages according to the National Pressure Ulcer Advisory Panel (NPUAP) classification.
    • Stage I: erythema of localized area, usually nonblanching over bony surface; may be painful, have consistency or temperature difference from surrounding tissue
    • Stage II: partial loss of dermal layer, resulting in pink ulceration; may be fluid-filled blister, or shiny, dry ulcer
    • Stage III: Full dermal loss often exposing subcutaneous tissue and fat.
    • Stage IV: Full-thickness ulceration exposing bone, tendon, or muscle. Osteomyelitis may be present.
  • Synonym(s): decubitus ulcer; bed sores
2.5 million pressure ulcers treated yearly in United States in acute care facilities (1)
  • Acute care 0.4-38%; long-term care 2.2-23.9%; home care 0-17%
  • Majority occur in patients >65 years: 36% with hip fracture, 50% in ICU care (2)
  • Pathophysiology of pressure ulcers is changing, differs depending on stage of ulceration.
  • Stages I to II result largely from prolonged moisture and friction and may not even be related to pressure and hypoxia, as previously believed (3).
  • Stages III to IV likely begin with compressive forces, causing muscle damage and tissue hypoxia and leading to reperfusion injury of the deep tissue. The skin ulcer forms after significant deep tissue damage is already under way (3).
  • Shearing and friction forces are also components of some ulcer formation, resulting in localized skin damage and early-stage ulcers (3).
  • Immobility: greatest risk factor regardless of patient, temporary or permanent immobility (4)
  • Urinary and fecal incontinence present in >80% of immobile patients with pressure ulcers
  • Poor nutritional status: Hypoalbuminemia and low BMI are markers for poor ulcer outcome (4).
  • Poor skin perfusion, including vascular disease, diabetes, anemia, and tobacco use, increases risk.
  • Extended stay in hospital/nursing home, inadequate staffing (5)
  • Other risks include history of previous ulcer, age-related skin changes, immunocompromise, impaired skin sensation, and impaired awareness.
  • Assessment scales commonly used for risk evaluation include Braden and Norton scales. The use of these does not decrease incidence, but they are more accurate than clinical judgment alone (6)[A].
  • Up to 95% are preventable; identification of at-risk patients within 8 hours of admission, with early multidisciplinary care
  • Skin assessment: policy in all health care settings (5)[B]
    • Increase frequency of assessments with decline in clinical condition (5)[C].
    • Include erythema, edema, skin temperature, and consistency in all evaluation (5)[B].
    • Assess around medical devices twice daily (5)[C].
  • Pressure relief
    • Establish pressure relief schedule.
    • Proper patient positioning and the use of mattresses, cushions, heel protectors, and other devices to minimize pressure and friction
    • Regular turning of patients, including the use of angles and rotation of extremities, helps to minimize pressure.
  • Avoid positioning on area of erythema (5)[C].
  • Minimize duration of immobility: adequate physical and occupational therapies when appropriate
  • Aggressive moisture prevention: management plan for incontinence (5)[C]
  • Nutrition
    • Complete assessment of nutritional status and form plan, particularly protein intake and albumin levels.
    • Reassess with all changes in condition.
    • Develop individualized nutritional care plan for protein, calories, vitamins, and hydration (5)[C].
  • Manage skin health: clean and dry with mild cleansers, skin protection where appropriate. Avoid massage or rubbing skin prone to ulcers (5)[C].
  • Microclimate control: emerging therapy, control moisture, and temperature when selecting support structure. Avoid use of heating devices (5)[C].
  • Prophylactic dressings: emerging therapy, apply foam dressing to bony prominences to avoid friction and shear (5)[B].
  • Textiles and fabrics: Sheets and clothing should be silk-like rather than cotton or other abrasives.
See “Risk Factors.”
  • Do full skin examination on admission to hospital or extended-care facility and repeatedly throughout admission, best with bathing/bed changes.
  • 83% of hospitalized patients with decubitus ulcers develop them in first 5 days of hospitalization.
  • Classify ulcer based on NPUAP stages (see “Description”).
    • Focus on skin color, consistency, and temperature changes when classifying ulcer.
    • Assess and document location, category, size, tissue, color, edges, sinus tracts, exudate, odor.
    • Assess pain (5)[B].
  • Venous stasis ulcers
  • Arterial ulcers resulting from poor vascular supply
  • Diabetic ulcers
  • Pyoderma gangrenosum, cancers, vasculitides, and other dermatologic conditions
Initial Tests (lab, imaging)
  • Wound culture: Do not culture surface drainage. If culture necessary, do deep tissue culture/bone biopsy.
  • If systemic infection or that of bone, muscle is suspected, add infectious workup, including inflammatory markers, CBC, blood cultures, x-ray. MRI may be necessary to confirm osteomyelitis.
  • Nutritional assessment: BMI, protein and calorie intake, albumin, prealbumin, CBC for anemia. No clear evidence in support of specific nutritional supplements including zinc and vitamin C (7)[A],(8)[B].
Follow-Up Tests & Special Considerations
Additional tests may be indicated when additional medical illness complicates assessment. This may include testing for diabetes, vascular disease, and other dermatologic diagnoses.
  • Pressure reduction, minimize immobility, manage incontinence, and improve nutritional status and skin health (as described in “Prevention”)
  • Wound management by stage of ulcer
    • Stage I: aggressive preventive measures, thin film dressings for protection
    • Stage II: occlusive dressing to maintain healing, transparent films, hydrocolloids
    • Stages III to IV: débridement of necrotic tissue. Exudative ulcers will benefit from absorptive dressings such as calcium alginates, foams, hydrofibers. Dry ulcers require occlusive dressing to maintain moisture, including hydrocolloids, and hydrogels.
    • P.849

    • Débridement: type depends on extent of necrosis or eschar, or presence of biofilm; incisional with scalpel when extensive dry. Mechanical with wet-dry dressings; enzymatic débridement is also frequently used. Débride only when there is adequate perfusion to wound.
    • Surgical closure may be necessary in advanced wounds.
  • Vacuum-assisted closure
    • Negative pressure reduces wound edema and improves local tissue perfusion.
    • Removes necrotic debris and reduces bacterial load
    • Literature review demonstrates the efficacy of negative-pressure wound therapy (9)[A].
  • Dressings: mixed evidence for improvement (10)[B]
    • Select based on wound, exudate, ulcer stage.
    • Gauze: Avoid use, if no other options, wet-to-dry only.
    • Hydrocolloid: clean, shallow Stage II, not infected
    • Transparent: autolytic débridement, not for use on heavy exudate or over enzymatic debriding agents
    • Hydrogel: Stage II, shallow, minimal exudate, not infected
    • Alginate: Stage II to III, shallow with heavy exudate, infected, long duration dressing
    • Foam: Stage II to III, shallow with heavy exudate
    • Collagen-matrix: nonhealing Stage III to IV
    • Silver impregnated: infected or heavily colonized, high risk infection, short duration only
    • Honey impregnated: Stage II/III
    • Cadexomer iodine: Stage II/III with heavy exudate
First Line
  • See “General Measures” for first-line treatment.
  • Pain control
  • Aggressive management of contributing medical conditions
  • Infection: If suspected, treat appropriately for cellulitis or osteomyelitis.
    • High index of suspicion for infection: poor healing, odor, pain, warmth, drainage, necrosis, diabetes, malnutrition, poor perfusion, immunosuppression, culture with >105 cfu/g or GBS presence
  • Topical therapy
    • Débride as indicated
    • Nontoxic topical anesthetics including iodine, silver sulfadiazine, chlorhexidine (avoid hydrogen peroxide, Dakin solution) (5)[C]
Second Line
Nutritional interventions as determined by nutritional assessment. Weak evidence to support protein supplementation to reduce wound size (10)[C]
  • Vascular surgery is a consideration for improvement of blood flow to wound via vascular bypass.
  • Plastic surgery is a consideration for skin graft/flap.
  • Alternative therapies
    • Light, laser, acoustic have little shown benefit.
    • Whirlpool contraindicated (5)[B]
    • Electrical stimulation shows some benefit (10)[B].
  • Nutritional support as needed
  • Ultrasound and electrical stimulation create new vasculature in affected region (9)[C].
Admission Criteria/Initial Stabilization
Refractory cellulitis, osteomyelitis, systemic infection, advanced nutritional decline, suspected patient mistreatment, inability to care for self
  • Dressing changes 1 to 3 times daily based on wound assessment and plan of care
  • Assess risk factors according to scales.
  • Assess for new or changing wounds.
Discharge Criteria
Clinical improvement in wound and systemic illness; when applicable, safe, and appropriate location for discharge
Weekly assessment by nurse with wound experience; biweekly assessment by physician
Patient Monitoring
  • Home health nursing
  • Change in plan of care if no improvement in 2 to 3 weeks
  • 1 to 1.5 kg/day of protein
  • Good glycemic control
  • Include supply of micronutrients in diet or as supplements.
  • Check skin regularly.
  • Signs and symptoms of infection
  • Report new or increased pain.
  • Prevention of new wound where old wound healed
  • Skin care, moisture prevention
Variable, depending on the following:
  • Removal of pressure
  • Nutrition
  • Wound care
1. Reddy M, Gill S, Rochon P. Preventing pressure ulcers: a systematic review. JAMA. 2006;296(8):974-984.
2. Baumgarten M, Margolis DJ, Orwig DL, et al. Pressure ulcers in elderly patients with hip fracture across the continuum of care. J Am Geriatr Soc. 2009;57(5):863-870.
3. Sibbald RG, Krasner DL, Woo KY. Pressure ulcer staging revisited: superficial changes & Deep Pressure Ulcer Framework. Adv Skin Wound Care. 2011;24(12):571-580.
4. Cakmak S, Gül U, Ozer S, et al. Risk factors for pressure ulcers. Adv Skin Wound Care. 2009:22(9):412-415.
5. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Washington, DC: National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance; 2014.
6. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, et al. Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs. 2006;54(1):94-110.
7. Langer G, Schloemer G, Knerr A, et al. Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database Syst Rev. 2003;(4):CD003216.
8. Jamshed N, Schneider E. Is the use of supplemental vitamin C and zinc for the prevention and treatment of pressure ulcers evidence based? Ann Long-Term Care Med. 2010;18(3):28-32.
9. Gregor S, Maegele M, Sauerland S, et al. Negative pressure wound therapy: a vacuum of evidence? Arch Surg. 2008;143(2):189-196.
10. Qaseem A, Humphrey LL, Forciea MA, et al. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015;162(5): 370-379.
Additional Reading
Stansby G, Avital L, Jones K, et al. Prevention and management of pressure ulcers in primary and secondary care: summary of NICE guidance. BMJ. 2014;348:g2592.
  • L89.95 Pressure ulcer of unspecified site, unstageable
  • L89.91 Pressure ulcer of unspecified site, stage 1
  • L89.92 Pressure ulcer of unspecified site, stage 2
Clinical Pearls
  • Create assessment and prevention protocols for all patients.
  • Identify risk, reduce pressure, maximize nutrition, regular skin checks, and assess and treat wound appropriately.
  • All care needs to be done in time-sensitive, patient-centered fashion.