Pressure Ulcers

Introduction | Aetiology and Risk Factors | Clinical Presentation | Diagnosis | Management and Treatment | Prevention | When to Refer | References

Introduction

Pressure ulcers, also known as bedsores or decubitus ulcers, are localised injuries to the skin and underlying tissue, primarily caused by prolonged pressure or friction. They most commonly develop over bony prominences, such as the sacrum, heels, elbows, and hips. Pressure ulcers are a significant health concern, particularly in patients with limited mobility, and can lead to serious complications, including infection and prolonged hospitalisation. Early detection and management are crucial in preventing their progression.

Aetiology and Risk Factors

Pressure ulcers result from sustained pressure that impairs blood flow to the skin and underlying tissues, leading to ischaemia, tissue damage, and necrosis. Several factors contribute to the development of pressure ulcers:

• Immobility: Patients who are bedridden, wheelchair-bound, or have limited mobility are at high risk due to prolonged pressure on specific areas.
• Reduced Sensation: Conditions such as spinal cord injury, neuropathy, or sedation can impair a patient's ability to sense discomfort and relieve pressure, increasing the risk of ulcers.
• Poor Nutrition: Malnutrition and dehydration can lead to weakened skin integrity, making it more susceptible to breakdown.
• Moisture: Excess moisture from incontinence, perspiration, or wound exudate can macerate the skin, increasing the risk of ulceration.
• Ageing Skin: Older adults are more prone to pressure ulcers due to thinner, less elastic skin and reduced blood flow.
• Chronic Medical Conditions: Conditions such as diabetes, vascular disease, and heart failure can impair circulation and wound healing, increasing the risk of pressure ulcers.
• Friction and Shear: Movement or repositioning of patients can cause friction and shear forces, leading to skin breakdown, particularly when combined with pressure.

Clinical Presentation

Pressure ulcers are classified into stages based on the depth of tissue involvement:

Stage 1

• Non-Blanchable Erythema: Intact skin with non-blanchable redness over a bony prominence. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.

Stage 2

• Partial-Thickness Skin Loss: Involves the epidermis and possibly the dermis. The ulcer presents as an open sore or blister with a red or pink wound bed, without slough.

Stage 3

• Full-Thickness Skin Loss: Extends into the subcutaneous tissue but does not expose bone, tendon, or muscle. The ulcer may appear as a deep crater, with or without undermining or tunnelling.

Stage 4

• Full-Thickness Tissue Loss: Involves exposure of bone, tendon, or muscle. Slough or eschar may be present, and there may be tunnelling or undermining. These ulcers are at high risk for osteomyelitis and sepsis.

Unstageable

• Obscured Full-Thickness Skin and Tissue Loss: The extent of tissue damage cannot be determined because it is obscured by slough or eschar. Once removed, a Stage 3 or Stage 4 ulcer will be revealed.

Deep Tissue Injury

• Persistent Non-Blanchable Deep Red, Maroon, or Purple Discolouration: Skin may be intact or not intact, with underlying tissue damage. The area may be painful, firm, mushy, boggy, warmer, or cooler compared to adjacent tissue.

Diagnosis

The diagnosis of pressure ulcers is primarily clinical, based on the appearance of the skin and underlying tissues:

• History: Take a thorough history, including the patient's mobility, nutritional status, and any comorbid conditions that may contribute to skin breakdown.
• Physical Examination: Inspect all areas of the body, particularly bony prominences, for signs of pressure damage. Palpate for areas of induration, warmth, and tenderness.
• Staging: Classify the ulcer according to the staging system described above to guide management.
• Laboratory Tests: If infection is suspected, consider ordering a full blood count (FBC), inflammatory markers (CRP, ESR), and wound swabs for culture and sensitivity. Blood cultures may be indicated if sepsis is suspected.
• Imaging: In cases of suspected underlying osteomyelitis, X-rays, MRI, or bone scans may be necessary.

Management and Treatment

Effective management of pressure ulcers involves a multidisciplinary approach, focusing on wound care, pressure relief, and addressing underlying factors:

1. Wound Care

• Cleansing: Clean the ulcer with saline or a non-cytotoxic wound cleanser. Avoid using antiseptics that can delay healing.
• Debridement: Remove necrotic tissue to promote healing. Debridement methods include autolytic (using dressings), enzymatic, mechanical, and surgical debridement, depending on the wound and patient condition.
• Dressings: Select dressings based on the ulcer's characteristics. Options include hydrocolloids, hydrogels, foams, alginates, and antimicrobial dressings. The goal is to maintain a moist wound environment while managing exudate.
• Infection Control: If infection is present, topical antimicrobials may be used, and systemic antibiotics may be indicated based on culture results and clinical signs of infection.
• Negative Pressure Wound Therapy (NPWT): NPWT may be beneficial for large or complex wounds, promoting healing by reducing oedema, increasing blood flow, and removing exudate.

2. Pressure Relief

• Repositioning: Regularly reposition patients to relieve pressure on vulnerable areas. Ideally, patients should be repositioned every 2 hours.
• Support Surfaces: Use specialised mattresses, cushions, and overlays designed to redistribute pressure and reduce the risk of ulcer formation.
• Mobility Promotion: Encourage and assist patients to mobilise as much as possible, which can help prevent pressure ulcers and promote overall health.

3. Nutrition

• Nutritional Assessment: Assess the patient’s nutritional status, as malnutrition is a significant risk factor for pressure ulcers.
• Dietary Interventions: Provide a high-protein, high-calorie diet with adequate vitamins and minerals to support wound healing. Supplementation with vitamin C, zinc, and arginine may be beneficial.
• Hydration: Ensure adequate fluid intake to maintain skin integrity and overall health.

4. Pain Management

• Analgesics: Provide appropriate pain relief, including paracetamol, NSAIDs, or opioids for more severe pain.
• Topical Analgesia: Consider topical lidocaine or other local anaesthetics for painful ulcers during dressing changes.

5. Surgical Intervention

• Surgical Debridement: For extensive necrosis or infected wounds, surgical debridement may be necessary to remove dead tissue and promote healing.
• Flap Surgery: In cases of large or non-healing ulcers, reconstructive surgery with flap closure may be required to cover the wound and prevent recurrence.

Prevention

Preventing pressure ulcers is a key aspect of care, particularly in at-risk populations:

• Risk Assessment: Regularly assess patients using tools such as the Waterlow score or Braden scale to identify those at high risk of pressure ulcers.
• Skin Inspection: Perform daily skin inspections to detect early signs of pressure damage, particularly in high-risk areas.
• Repositioning: Encourage frequent repositioning, as well as the use of pressure-relieving devices such as mattresses and cushions.
• Nutrition and Hydration: Ensure adequate nutrition and hydration to maintain skin integrity.
• Education: Educate patients, caregivers, and healthcare staff about the importance of pressure ulcer prevention strategies.

When to Refer

Referral to a specialist may be necessary in the following situations:

• Non-Healing Ulcers: If a pressure ulcer fails to show signs of healing despite appropriate care, referral to a wound care specialist or dermatologist is advised.
• Infection: Severe or spreading infections may require referral for systemic antibiotic therapy and further investigation.
• Osteomyelitis: Suspected underlying bone infection should prompt referral to a specialist for further management, including imaging and possible surgical intervention.
• Surgical Needs: Large or complex ulcers that may benefit from surgical debridement or reconstruction should be referred to a plastic surgeon or specialist wound care team.

References

1. National Institute for Health and Care Excellence (2024) Pressure Ulcers: Prevention and Management. Available at: https://www.nice.org.uk/guidance/ng198 (Accessed: 26 August 2024).
2. British Association of Dermatologists (2024) Guidelines for the Management of Pressure Ulcers. Available at: https://www.bad.org.uk (Accessed: 26 August 2024).
3. British National Formulary (2024) Wound Management and Dressings. Available at: https://bnf.nice.org.uk/ (Accessed: 26 August 2024).