Diagnosis and Management of Pressure Ulcers

Leading research estimates a prevalence of up to 27% of pressure ulcers in patients living at long-term care facilities. Elderly patients (above 70 years of age), obese patients, patients with limited mobility, and those with underlying medical conditions e.g., peripheral arterial disease, and multiple sclerosis are the most at risk of developing pressure ulcers. 

What are pressure ulcers?

Pressure ulcers (aka decubitus ulcers or bedsores) are lesions resulting from unrelieved pressure on any part of the body as well as physiological factors that promote ulcerations. The most commonly affected areas, however, are bony prominences such as the scapula, occiput, elbows, sacrum, and ischium. Risk factors affecting the development of pressure ulcers include vascular disease, diabetes, immunosuppression, spinal cord injury, smoking, and malnutrition. 

Are pressure ulcers slow-healing?

According to the Wound Healing Society, pressure ulcers, diabetic foot ulcers, venous insufficiency ulcers, and arterial insufficiency ulcers all fall into the category of chronic non-healing wounds. Chronic wounds do not exhibit a predictable progression of wound healing and may last anywhere from a few weeks to many years. 

Symptoms and diagnosis

The most common symptoms of pressure ulcers include:

• Skin discoloration (a pale red discoloration in patients with lighter skin and blue or purple patches in dark-skinned patients that do not turn white when pressed)
• Pain and tenderness in the affected area
• Itchiness of the skin
• Odor due to accumulation of exudate in the wound

Stages of pressure ulcerations

Further assessment of the site of a pressure ulcer will reveal the condition of peri-wound skin, the amount of exudate, and whether there is tissue undermining or tunneling. There are six progressive stages of pressure ulcers based on the severity. In stage 1 pressure ulcers, the skin is intact, with non-blanchable erythema. The second stage typically includes an open wound or blister with partial-thickness skin damage. However, there is no visible subcutaneous tissue. The third stage shows full-thickness skin damage with a visible layer of subcutaneous fat. Stage 4 ulceration exposes tendons, bones, and muscles along with subcutaneous tissue. Stages 5 (unstageable) and 6 (deep-tissue injury) are advanced ulcerations where the wound bed is completely covered in slough or eschar or where the depth of tissue injury is unknown. 

Treatment of pressure ulcers

Pressure ulcers are both preventable and treatable by healthcare professionals. There are four major techniques for treatment, namely; pressure relief, infection control, debridement of slough and necrotic tissue, and specialized wound care to facilitate wound healing. 

Relieving pressure at the wound site

Reducing the amount of pressure on the wound site is the first step in the treatment of pressure ulcers. A common way to do this is by applying pads at pressure points to minimize shearing forces. For bedridden patients or those with limited mobility due to wheelchair use, the person must be repositioned regularly. Special mattresses and cushions can also relieve pressure; either through static or dynamic mechanisms. 

Wound disinfection

infection control in pressure ulcers involves initial wound assessment to determine if there is an infection at the wound site. The presence of necrotic soft tissue, erythema, and fluctuance can indicate that there is a localized infection requiring urgent treatment to prevent proliferation. 

Infection control is carried out in an operating room and usually involves the use of antiseptics such as povidone-iodine (PVP-I), Dakin's solution, and hydrogen peroxide to clean the wound site. Antiseptics help to kill bacteria and also promote wound healing. In special cases (e.g., patients with evidence of osteomyelitis), the use of intravenous antibiotics may be appropriate. 

Debridement

Wound debridement of pressure ulcers involves the mechanical removal of necrotic soft tissue, abscess drainage, and biofilm from the wound site. The initial process is surgical (operative) debridement followed by routine debridement at the patient's bedside. Methods of debridement include hydrotherapy (e.g., wound irrigation with or without suction) or ultrasonic (using low-frequency acoustics) to displace dead soft tissue. 

Wound dressings 

Wound dressings are used to cover the wound bed, prevent bacterial intrusion, and provide a moist wound environment to promote wound healing. The type of dressing selected will depend on several factors including the size, location, amount of exudate, and the nature of peri-wound skin. Examples of wound dressings suitable for managing pressure ulcers include gauze, foam, hydrogel, hydrocolloid, and alginate. Most wound dressings consist of absorbent materials and some dressings (e.g., silver dressings) are impregnated with antibacterial solutions to prevent wound infections. They may require frequent replacement as wound healing progresses. 

Amputation Prevention in At-risk Populations With The Wound Docs

Pressure ulcers are a leading cause of amputations annually and underserved and under resourced populations such as African Americans are at significantly higher risk of losing their limbs. The Wound Docs is a national network of podiatric surgeons, vascular surgeons, and wound care specialists dedicated to reducing the amputation rate in vulnerable populations across the country.