Steven Tam
Objectives
Understand the definitions and staging
system for Pressure Ulcers
 Review the epidemiology
 Review risk factors for pressure ulcer
development
 Review and understand prevention and
treatment of pressure ulcers

Case
The Case of “Just a Hygiene
Problem”

Patient: 78 year old woman
 lives with her son (primary caregiver)
 history of diabetes
 difficulty walking (spinal stenosis?),
wheelchair bound
 chronic edema
 brought in to the ER for altered mental
status
 found to have a UTI
4
The Case of “Just a Hygiene
Problem”
Skin not checked until the patient
transferred to the ward floor
 The RN notifies the Attending regarding
the skin
 The Attending says “it’s normal and just
a hygiene problem” to nurse, in front of
all other staff
 Nurse calls APS

5
Is this normal?
6
PRESSURE ULCER: DEFINITION

Skin lesion caused by unrelieved pressure resulting
in damage to soft tissue compressed between a
bony prominence and external surface over a
prolonged period of time

The time for pressure ulcer development is variable
due to severity of illness and number of comorbid
conditions

Normal wound healing: Homeostasis,
inflammatory, proliferative and maturation
 Aging can affect the wound healing process/phases
Pressure Ulcers
8
Pressure Sores
September 2013
National Institute on the Prosecution of Elder Abuse
9
STAGING OF PRESSURE ULCERS
(1 of 5)
Stage
Suspected
deep tissue
injury
Definition
•
•
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
than adjacent tissue
Comments
• Deep tissue injury can be
difficult to detect in individuals
with dark skin tones
• Evolution can include a thin
blister over a dark wound bed
• The wound can further evolve
and become covered by thin
eschar
• Evolution can be rapid and
expose additional layers of
tissue, even with optimal
treatment
Staging according to the National Pressure Ulcer Advisory Panel
STAGING OF PRESSURE ULCERS
(2 of 5)
Stage
Definition
Comments
Stage I
• Intact skin with nonblanchable • The area may be painful, firm,
redness of a localized area
soft, and warmer or cooler than
usually over a bony
adjacent tissue
prominence
• Stage I can be difficult to detect
• Darkly pigmented skin may not
in individuals with dark skin
have visible blanching; its color
tones
may differ from the surrounding
area
Stage II
• Partial-thickness loss of dermis • Presents as a shiny or dry
presenting as a shallow open
shallow ulcer without slough or
ulcer with a red-pink wound
bruising (the latter indicates
bed, without slough
suspected deep tissue injury)
• Can also present as an intact • This stage should not be used to
or open/ruptured serum-filled
describe skin tears, tape burns,
blister
perineal dermatitis, maceration,
or excoriation
STAGING OF PRESSURE ULCERS
(3 of 5)
Stage
Definition
Comments
Stage III • Full-thickness tissue loss
• Depth varies by anatomic
• Subcutaneous fat can be
location The bridge of the nose,
visible but bone, tendon, or
ear, occiput, and malleolus do
muscle are not exposed
not have subcutaneous tissue,
• Slough may be present but
and Stage III ulcers can be
does not obscure the depth
shallow
of tissue loss
• In contrast, areas of significant
• Can include undermining
adiposity can develop extremely
and tunneling
deep Stage III pressure ulcers
Bone/tendon is not visible or
directly palpable
STAGING OF PRESSURE ULCERS
(4 of 5)
Stage
Definition
Stage IV • Full-thickness
tissue loss with
exposed bone,
tendon, or muscle
• Slough or eschar
can be present on
some parts of
wound bed
• Often include
undermining and
tunneling
Comments
• Depth varies by anatomic location
• The bridge of the nose, ear, occiput, and
malleolus do not have subcutaneous
tissue, and these ulcers can be shallow
• Stage IV ulcers can extend into muscle
and/or supporting structures (eg, fascia,
tendon or joint capsule), making
osteomyelitis possible
• Exposed bone/tendon is visible or
directly palpable
STAGING OF PRESSURE ULCERS
(5 of 5)
Stage
Unstageable
Definition
Comments
• Full-thickness
• Until enough slough and/or
tissue loss in which
eschar is removed to expose the
the base of the
base of the wound, the true
ulcer is covered by
depth (and therefore stage)
slough (yellow, tan,
cannot be determined
gray, green, or
• Stable (dry, adherent, intact
brown) and/or
without erythema or fluctuance)
eschar (tan, brown,
eschar on the heels serves as
or black) in the
“the body's natural (biological)
wound bed
cover” and should not be
removed
Epidemiology: Pressure Ulcers

Affect 1 million adults annually

Higher risk in older people because:
•
•
•
•
•
Local blood supply to skin decreases
Epithelial layers flatten and thin
Subcutaneous fat decreases
Collagen fibers lose elasticity
Tolerance to hypoxia decreases

1 of 3 sentinel events for long-term care

Medicare and most states’ Medicaid programs do
not pay for hospital-acquired stage III or IV
pressure ulcers
INCIDENCE OF PRESSURE ULCERS VARIES
BY SETTING
18
16
14
12
10
8
6
4
2
0
0–17%
11%
7%–9%
Hospital
Home Care
Nursing Home
PREVALENCE OF PRESSURE ULCERS
VARIES BY STAGE
Stages III &
IV, 20%
Stage I,
47%
Stage II,
33%
POSSIBLE COMPLICATIONS

Sepsis (aerobic or anaerobic bacteremia)

Localized infection, cellulitis, osteomyelitis

Pain

Depression
Mortality rate = 60% in older people who
develop a pressure ulcer within 1 year of
hospital discharge
RISK FACTORS

Intrinsic: physiologic factors or disease states that
increase the risk for pressure ulcer development
 Age
 Nutritional status
 Decreased arteriolar blood pressure

Extrinsic: external factors that damage skin
 Pressure, friction, shear
 Moisture, urinary, or fecal incontinence
FACTORS PREDICTIVE OF
PRESSURE ULCER DEVELOPMENT








Age 70+
Impaired mobility
Current smoking
Low BMI
Confusion
Urinary and fecal
incontinence
Malnutrition
Restraints

Many other disorders:
malignancy, diabetes,
stroke, pneumonia,
CHF, fever, sepsis,
hypotension, renal
failure, dry skin, history
of pressure ulcers,
anemia, lymphopenia,
hypoalbuminemia
RISK ASSESSMENT INSTRUMENTS
Widely used tools for identifying older patients at
risk of developing ulcers:

Norton scale
Sensitivity = 73%–92%, specificity = 61%–94%

Braden scale
Sensitivity = 83%–100%, specificity = 64%–77%
Both are recommended by Agency for Healthcare
Research and Quality
NORTON SCALE
Provides method for assessing a patient’s
pressure ulcer risk by evaluating:
○ Physical condition
○ Mental condition
○ Level of physical activity
○ Mobility
○ Continence or incontinence
BRADEN SCALE
Provides method for assessing pressure ulcer risk
by evaluating:
• Sensory perception: ability to respond to pressure-
related discomfort
• Moisture: degree of exposure to moisture
• Activity: degree of physical activity
• Mobility: ability to change and control body position
• Nutrition: usual food intake
http://www.bradenscale.com/
Prevention and Treatment
PREVENTION
An evidence-based approach to preventing
pressure ulcers focuses on:
○ Skin care
○ Nutrition
○ Mechanical loading
○ Mobility
○ Support surfaces
PREVENTION: SKIN CARE (1 of 2)

Daily systematic skin inspection and cleansing
 Especially bony prominences
 Use warm water and mild cleanser

Reduce factors that promote dryness
 Avoid low humidity and exposure to cold
 Moisturize dry skin

Avoid massaging over bony prominences
PREVENTION: SKIN CARE (2 of 2)

Reduce moisture
 Incontinence
 Perspiration
 Drainage

Minimize friction and shear
 Use proper repositioning, turning, transferring
techniques
 Use lubricants, protective films, dressings, padding
PREVENTION: NUTRITION

Maintaining optimal nutrition continues to be part
of national pressure ulcer prevention guidelines
 However, the relationship between protein-calorie
malnutrition and its relationship with pressure
ulcer development is unclear

Avoid over-supplementing patients who do not
have protein, vitamin, or nutritional deficiency

Review goals of care prior to considering enteral
or parenteral nutrition
PREVENTION:
MECHANICAL LOADING

Reposition at least every 2 h (may use pillows, foam
wedges)

Use lubricants and protective dressings/pads

Keep head of bed at lowest elevation possible

Use lifting devices to decrease friction and shear

Remind patients in chairs to shift weight every 15 min
 “Doughnut” seat cushions are contraindicated, as
they may cause pressure ulcers

Pay special attention to heels (account for 20% of all
pressure ulcers)
PREVENTING HEEL ULCERS (1 of 2)

Assess heels of high-risk patients every
day

Use moisturizer on heels (no massage)
twice a day

Apply dressings to heels:
 Transparent film for patients prone to friction
problems (eg, stroke patients)
 Single or extra-thick hydrocolloid dressing for
those with pre-stage I reactive hyperemia
PREVENTING HEEL ULCERS (2 of 2)

Have patients wear:
 Socks to prevent friction (remove at bedtime)
 Properly fitting sneakers or shoes when in wheelchair

Place pillow under legs to keep heels off bed

Turn patients every 2 hours, repositioning heels
STATIC SUPPORT SURFACES
Support area
Low moisture
retention
Reduced heat
accumulation
Shear reduction
Pressure
reduction
Cost per day
Foam
Yes
Standard
mattress
No
Static flotation,
air or water
Yes
No
No
No
No
No
No
No
Yes
No
No
Yes
Yes
Low
Low
Low
DYNAMIC SUPPORT SURFACES
Support area
Low moisture
retention
Reduced heat
accumulation
Shear reduction
Pressure
reduction
Cost per day
AirLow air
fluidized loss
Alternating air
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
?
Yes
Yes
Yes
High
High
Moderate
MANAGEMENT:
GENERAL ASSESSMENT
Identify and effectively manage issues that have
placed patient at risk of pressure ulcers:

Medical diseases

Health problems (eg, urinary incontinence)

Nutritional status

Pain level

Psychosocial health
MANAGEMENT:
ULCER ASSESSMENT
Evaluate and document:

Location
• Necrosis

Area
• Granulation

Stage
• Cellulitis

Depth
• Nonhealing wound

Drainage
MANAGEMENT:
MONITORING HEALING

Document all observations over time

Describe each ulcer to track progress of healing

Do not use “reverse staging”
 For example, stage IV cannot become stage III
 Ulcers are filled with granulation tissue (endothelial
cells, fibroblasts, collagen, extracellular matrix)
 Ulcers do not replace lost muscle, subcutaneous fat,
or dermis before re-epithelializing

Use validated tools (eg, PUSH, see next slide)
PRESSURE ULCER SCALE
FOR HEALING (PUSH)

A validated method to document healing over time

Observe and measure the ulcer’s:
 Surface area: measure with centimeter ruler
 Exudate: estimate portion of ulcer bed covered by
drainage
 Appearance: estimate portion of ulcer for each tissue
type (epithelial, granulation, slough, necrotic)

Assign weighted score to obtain total score; total scores
over time indicate healing or deterioration
MANAGEMENT:
CONTROL OF INFECTIONS (1 of 2)

Wound cleansing and dressing are the keys
 Increase frequency when purulent or foul-smelling
drainage is first observed
 Avoid topical antiseptics because of their tissue
toxicity

With failure to heal or persistent exudate after 2 weeks
of optimal cleansing, consider trial of topical antibiotics

Avoid routine swab cultures
MANAGEMENT:
CONTROL OF INFECTIONS (2 of 2)

If still no healing, consider possible cellulitis or
osteomyelitis
 Biopsy for culture of underlying tissue, bone
 May need systemic antibiotics
MANAGEMENT:
METHODS OF DEBRIDEMENT
Type
Methods
Comments
Mechanical
Wet-to-dry irrigation,
hydrotherapy
May remove both dead and
live tissue; may be painful
Surgical,
sharp
Scalpel, scissor to
Quick, effective; use for
remove dead tissue; laser infection; pain management
debridement
needed
Enzymatic
Topical agent to dissolve
dead tissue
Use if no infection; may
damage skin
Autolytic
Allows dead tissue to
self-digest
Use if other methods not
tolerated and no infection;
effect delayed
Biosurgery
Larvae to digest dead
tissue
Quick, effective, good option
when surgical debridement
not an option
MANAGEMENT: DRESSINGS (1 of 3)

Transparent film: stage I, protects from friction
Contraindicated: draining, suspected infection or
fungus

Foam island: stages II, III
Contraindicated: excessive exudate; dry, crusted
wound

Hydrocolloid: stages II, III
Contraindicated: poor skin integrity, infection, wound
needs packing

Petroleum-based nonadherent: stages II, III, graft sites
MANAGEMENT: DRESSINGS (2 of 3)

Alginate: stages III and IV, excessive drainage
Contraindicated: dry or superficial wound with
maceration

Hydrogel, amorphous: stages II, III, IV; must combine
with gauze dressing
Contraindicated: maceration, excess exudate

Hydrogel, sheet: stage II, skin tears
Contraindicated: maceration, moderate to heavy
exudate
MANAGEMENT: DRESSINGS (3 of 3)

Gauze packing: stages III, IV
Contraindicated: deep wounds, especially those with
tunneling, undermining

Consider silicone-based dressings to decrease pain

Silver dressings: malodorous wounds, exudative wounds,
and those highly suspicious for critical bacterial load
Contraindicated: systemic infection, cellulitis, fungus,
interstitial nephritis, skin necrosis, concurrent use with
proteolytic enzymes
MANAGEMENT: NUTRITION

Ensure adequate diet; prevent malnutrition

Weak evidence for nutritional support that
achieves 30 to 35 calories/kg/day and 1.25 to
1.5 g of protein/kg/day

Weak evidence for supplemental vitamins
and minerals
MANAGEMENT: SURGICAL REPAIR

May be used for stage III and IV ulcers
 Direct closure, skin grafting, skin flaps,
musculocutaneous flaps, free flaps

Risks and benefits of surgery must be carefully
weighed for each patient:
 Many stage III and IV ulcers heal over a long time
with local wound care
 Rate of recurrence of surgically closed pressure
ulcers is high
MANAGEMENT:
ADJUNCTIVE THERAPIES

No data to support low-energy laser irradiation,
therapeutic ultrasound, hyperbaric oxygen

Promising research continues:
 Recombinant platelet-derived growth factors
 Electrical stimulation
 Vegetative pressure wound therapy
SUMMARY

Older adults are at high risk of developing
pressure ulcers

Pressure ulcers may result in serious morbidity
and mortality

Techniques that reduce pressure, moisture,
friction, and shear can prevent pressure ulcers

Pressure ulcers should be treated with proper
cleansing, dressings, debridement, or surgery as
indicated
CASE 1 (1 of 3)

A 92-year-old woman is examined because a nurse
has identified a suspicious area of skin on the right
buttock.

The patient underwent open-reduction internal fixation
repair of a fractured right hip a few days earlier and
was transferred to the Acute Care for the Elderly
(ACE) unit from the surgery service.

On examination, there is a 4 cm × 4 cm area on the
right lateral buttock. It has a blood-filled blister that
remains intact with surrounding dark tissue.
CASE 1 (2 of 3)
Which of the following is the most effective
management for this finding?
A. Hyperbaric therapy
B. Electromagnetic therapy
C. Surgical debridement
D. Turning patient every 2 hours
CASE 1 (3 of 3)
Which of the following is the most effective
management for this finding?
A. Hyperbaric therapy
B. Electromagnetic therapy
C. Surgical debridement
D. Turning patient every 2 hours
CASE 2 (1 of 4)

A 72-year-old man who has metastatic colon cancer is
admitted to a hospice inpatient facility because of
complete bowel obstruction and failure to thrive. He
has been unable to tolerate oral food or fluids for
several days because of nausea and vomiting, and he
has significant pain throughout the day.

The hospice admitting nurse documents a large
sacral pressure ulcer measuring 11 cm × 10 cm, with
a depth of 4 cm. There is surrounding erythema,
exposed muscle, undermining of the edges, and a
tunneling tract that extends another 2 cm.
CASE 2 (2 of 4)

Within the ulcer, there is necrotic material and a
significant amount of exudate with a foul odor that
permeates the room.

The treatment plan includes placement of a
specialized bed overlay, application of absorptive
dressings, and medicine for pain control.

Family members tell staff that the wound odor makes
spending time in the patient’s room very difficult, and
they ask if something can be done.
CASE 2 (3 of 4)
Which of the following is the best next step to
reduce odor from the pressure ulcer?
A. Turn patient every 2 hours.
B. Apply topical metronidazole gel.
C. Place potpourri in the room.
D. Perform surgical debridement.
CASE 2 (4 of 4)
Which of the following is the best next step to
reduce odor from the pressure ulcer?
A. Turn patient every 2 hours.
B. Apply topical metronidazole gel.
C. Place potpourri in the room.
D. Perform surgical debridement.
CASE 3 (1 of 3)

A 68-year-old woman is transferred to a medical ward
after being treated in the intensive care unit for
respiratory failure due to COPD.

During an examination, the nurse notices an area of
skin breakdown on the patient’s coccyx. It is 3 cm × 4
cm with a depth of 1 cm and has minimal slough. The
wound edges are hyperemic, but there is no sign of
undermining. Wound exudate is minimal, and there
are no systemic signs of infection.
CASE 3 (2 of 3)
Which of the following is the most appropriate
treatment for this wound?
A. Alginate dressing
B. Hydrocolloid dressing
C. Transparent film
D. Wet-to-dry dressing
CASE 3 (3 of 3)
Which of the following is the most appropriate
treatment for this wound?
A. Alginate dressing
B. Hydrocolloid dressing
C. Transparent film
D. Wet-to-dry dressing
GRS8 Slides Editor:
Annette Medina-Walpole, MD, AGSF
GRS8 Chapter Author:
Courtney H. Lyder, ND
GRS8 Question Writer:
R. Morgan Bain, MD
Medical Writers:
Beverly A. Caley
Faith
Reidenbach
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2013 American Geriatrics Society