Pressure ulcer guidelines pdf

Pressure ulcers are largely preventable in nature, and their management depends on their severity. The available literature about severity of pressure ulcers, their classification and medical care protocols have been described in this paper.

The present treatment options include various approaches of cleaning the wound, debridement, optimised dressings, role of antibiotics and reconstructive surgery. The newer treatment options such as negative pressure wound therapy, hyperbaric oxygen therapy, cell therapy have been discussed, and the advantages and disadvantages of current and newer methods have also been described.

Pressure ulcers are a type of injury that breaks down the skin and underlying tissue when an area of skin is placed under constant pressure for certain period causing tissue ischaemia, cessation of nutrition and oxygen supply to the tissues and eventually tissue necrosis. The areas that are particularly prone to pressure sores are those that cover the bony areas such as occiput, trochanters, sacrum, malleoli and heel.

There are many factors that can contribute to the development of pressure ulcers, but the final common pathway to ulceration is tissue ischaemia.

The tissues are capable of sustaining pressure on the arterial side of around mm hg for only a small duration of time. But when pressure increases even slightly above this capillary filling pressure, it causes microcirculatory occlusion and this in turn initiates a downward spiral toward ischaemia, tissue death and ulceration.

Pressure ulcers can develop when a large amount of pressure is applied to an area of skin over a short period. They can also occur when less pressure is applied over a longer period. Blood vessels within the distorted tissue are compressed, angulated or stretched out of their usual shape and blood is unable to pass through them. Besides occluding the blood flow, tissue distortion also obstructs lymphatic flow, which in turn leads to accumulation of metabolic waste products, proteins and enzymes in the affected tissue.

This too can compound the tissue damage. The majority of people affected with pressure sores are those having health conditions mental or physical that encourage immobility, especially those who are confined to bed or chair for prolonged periods of time. Several other health conditions that influence blood supply and capillary perfusion, such as type-2 diabetes, can make a person more vulnerable to pressure ulcers.

Age is also a factor that the majority approximately two-third of pressure ulcers occur in old age people years of age. Majority of the patients affected with pressure ulcers frequently develop it over a bony prominence. As the living tissues are not static, the way they are distorted change over time.

When constant pressure is maintained, soft tissues mould themselves to accommodate the external shape. This is known as tissue creep. This distortion of internal conjugation of soft tissues are significantly high in paraplegic patients[ 11 ] and particularly in these susceptible patients, If ischaemia persists for h, necrosis takes place and pressure ulcers can occur within h.

The height of the available tissue cover over the bony prominence is not the only determining factor for developing pressure sores. Although the soles of the feet have a thin covering of soft tissue, they have a vasculature that is particularly well-adapted to withstand considerable distorting forces. On the sacrum and ischial tuberosity on the other hand, although there is a relatively thick covering of soft tissue and a wide supporting surface, the blood vessels are not adapted for weight-bearing, which means that even with fairly light compression, pressure ischaemia can develop rapidly.

Hence, soles of feet do not develop pressure sores even after prolong weight bearing in ambulatory patients unless there are underlying causes making them insensate and more prone to pressure damage. Shearing occludes flow more easily than compression for example, it is easier to cut off flow in a water hose by bending than by pinching it , so shear can be considered to be even more significant than pressure in the causation of pressure ulcers.

These are areas on which the body is frequently supported when in a position such as sitting or lying semi-recumbent which allows forward slide. Superficial pressure ulcers caused by shearing tend to have uneven appearance. Friction, along with pressure and shear, is also frequently cited as a cause of pressure ulcers.

In the indirect sense, friction is necessary to generate the shearing forces. Skin weakened by pressure ischaemia may be more susceptible to friction, and the two will act together to hasten skin breakdown.

Immobility is not a primary cause of pressure ulcers but in the presence of additional factors it can initiate them. Patients with a profound immobility but intact sensation rarely develop pressure ulcers when they can still communicate. Conversely, comatose patients, even with intact sensation, can develop pressure ulcer, as they cannot communicate regarding pain of increased pressure threshold.

The pain of tissue ischaemia ensures that these patients frequently ask for their position to be changed. Patients with orthopaedic casts should be encouraged to report any discomfort and pain in order to prevent iatrogenic pressure ulcers. It is a known fact that tissue distortion causes ischaemia that in turn stimulates protective movements to relieve pressure and circulatory activity to restore normal blood flow in the affected areas.

These protective movements are often reflexes as the person is unaware of making them. However, if these prompt actions prove insufficient to relieve ischaemia, the central nervous system is stimulated by constant signals of discomfort and pain to make sure that the pressure is relieved before any permanent damage occurs.

Once the pressure is relieved, and the circulation restored, local capillaries begin to dilate and increased blood flow takes place, referred to as reactive hyperaemia.

As a result, a bright pink transitory patch appears on the skin, often called blanching erythema because it blanches on pressure unlike the dull red non-blanching erythema that indicates tissue damage[ 15 ] [ Figure 1a ]. Reactive hyperaemia ensures a rapid restoration of oxygen and carbon dioxide balance; it also flushes out waste products.

Erythema subsides as soon as tissues are restored to their resting state. Patients who fail to produce reactive hyperaemia cannot recover from the pressure induced ischaemic episodes resulting permanent damage to the tissues. Clinically, this presents as white patches in pressure areas, which do not change colour rapidly to the red of reactive hyperaemia, as they would in a healthy person. Rather, the white patches remain for many minutes before slowly returning directly to a more normal skin colour with little or no reactive hyperaemia being observable.

When the reactive hyperaemia cycle ceases to function adequately, a pressure ulcer will almost certainly develop unless preventive action is taken. There are three predisposing factors for pressure ulcers:. The creation of a pressure ulcer can involve one or a combination of these factors. The diabetic patient with neuropathy of the feet is likely to have abnormal circulatory function in the involved area.

Age-related physiological alterations can lower the threshold for pressure-induced injury in elderly patients. For example, an increase in the fragility of blood vessels and connective tissue and a loss of fat and muscle leading to a reduced capacity to dissipate pressure. Oxygen is required for all stages of wound healing thus any condition that is associated with a low tissue oxygen tension is a major cause of pressure ulcers.

These include: Heart failure, atrial fibrillation, myocardial infarction, and chronic obstructive pulmonary disease. Contractures and spasticity can contribute by repeatedly exposing tissues to pressure through flexion of a joint. Loss of sensations, the pain signal that would normally cause an immobile individual to change position is lost.

Paralysis and insensibility may produce atrophy of the skin leading to a thinning. This renders the skin more susceptible to the friction and shear forces a patient experiences when being moved. Nutritional conditions such as malnutrition,[ 18 ] hypoproteinemia,[ 19 ] and anaemia[ 20 ] can cause significant delays in wound healing and hasten the formation of pressure ulcers. Moisture causes maceration, which predisposes the skin to injury. De-epithelialisation caused by trauma leads to transdermal water loss that creates maceration and adherence of the skin to clothing and any other supports in contact, resulting into further injury.

Mental health conditions - people with severe mental health conditions such as schizophrenia or severe depression have an increased risk of pressure ulcers for a number of reasons:.

They may neglect their personal hygiene, making their skin more vulnerable to injury and infection that help an ulcer to form. Healthcare professionals use several grading systems to describe the severity of pressure ulcers; most common is the EPUAP grading system.

Pressure sores are categorised into four stages [ Table 2 ] corresponding to the depth of damage. Grades of pressure ulcer [ Figure 1 ]. A grade one pressure ulcer is the most superficial type of ulcer. The affected area of skin appears discoloured and is red in white people, and purple or blue in people with darker coloured skin [ Figure 1a ]. One important thing to remember is that Grade 1 pressure ulcers do not turn white when pressure is placed on them.

The skin remains intact, but it may hurt or itch. It may also feel either warm and spongy or hard. Non-blanchable erythema of intact skin can be difficult to assess in patients with darkly pigmented skin.

In Grade 2 pressure ulcers, some of the outer surface of the skin the epidermis or the deeper layer of skin the dermis is damaged, leading to skin loss [ Figure 1b ]. The ulcer looks like an open wound or a blister. The characteristics are:. Partial thickness skin loss involving epidermis, dermis or both, for example, abrasion, blister or shallow crater. In Grade 3 pressure ulcers, skin loss occurs throughout the entire thickness of the skin. The underlying tissue is also damaged, but the underlying muscle and bone are not damaged.

The ulcer appears as a deep cavity like wound [ Figure 1c ]. Full thickness skins involving damage to or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. A Grade 4 pressure ulcer is the most severe type of pressure ulcer.

The skin is severely damaged, and the surrounding tissue begins to die tissue necrosis. The underlying muscles, bone or joint may also be damaged [ Figure 1d ], sometimes very severely [ Figure 1e ].

People with grade four pressure ulcers have a high risk of developing a life-threatening infection. Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, for example, tendon or joint capsule.

Undermining and sinus tracts may be associated with this stage of wound progression. Similar to grading a burn with the addition of a stage 4 that is deeper than a stage 3 ulcer or 3 rd degree burn. Where possible, treatment of ulcers is planned with an aim to reverse the factors that have originally caused the ulcer. Ulcers are often the result of combined pathology like diabetes, pressure, loss of sensation. Careful assessment is needed before planning for treatment.

In general the possible causative factor should be removed pressure, shear, friction and the associated general condition should be taken into the control like treatment of associated co-morbid illness and improvement in the nutrition.

The affected area requires thorough cleaning and dressing. The limb must be elevated to improve the venous and lymphatic drainage, and the part must be given some rest from the weight bearing, pressure and friction. However, since the full range of motion and active physiotherapy of joints do improve circulation, even non-weight bearing physiotherapy is desirable.

Wound healing requires adequate protein, iron, Vitamin-C and zinc. Supplements may be prescribed if they are deficient in the diet. Rest of the management of ulcer depends on many factors, and Table 3 illustrates an algorithm to help formulate a treatment plan. Various treatment options are available to treat pressure ulcers, they include:. Cleaning of the wound and meticulous skin care are the most essential part of the treatment.

The process involves removal of surface contamination and meticulous excision of all dead tissue. This is debridement. Besides the conventional surgical debridement other types of debridement like mechanical debridement which includes use of repeated wet to dry dressings to removes slough,[ 26 ] enzymatic debridement using enzymes to liquefy dead tissue in the wound and remove them with the dressings,[ 27 ] and biological debridement or maggots and larval therapy[ 28 , 29 ] in which the larvae eat all the dead tissue and make the wound clean without harming the living tissues also find a mention in literature.

Maggots also help to fight infection by releasing substances that kill bacteria and stimulate the healing process. Dead tissue may be removed using mechanical means.

Some mechanical debridement techniques include:. Where dead tissue is removed using high-pressure water jets. There is no evidence available to support any specific and effective cleansing techniques or solution, in particular. It provides a detailed analysis and discussion of available research, critical evaluation of the assumptions and knowledge in the field, recommendations for clinical practice, good practice statements, implementation considerations, a description of the methodology used to develop the guideline and acknowledgements of the many experts formally involved in the development process.

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The mainstays of treatment as outlined above include debridement of devitalized tissue, control of remaining infection with antibiotics, medical and nutritional patient optimization, appropriate dressing selection, and frequent monitoring of progression of wound evolution.

If standard approaches are not adequate, additional therapies can be pursued, including biophysical modalities. Finally, in large ulcers, ulcers where wound healing is not adequately progressing, or ulcers where chronic osteomyelitis is present, reconstructive surgery can be considered. The authors acknowledge generous support from the Hagey Laboratory for Pediatric Regenerative Medicine.

No competing financial interests exist. The content of this article was expressly written by the authors listed. No ghostwriters were used to write this article. Tatiana V. Boyko, MD, is a general surgery resident at the University at Buffalo currently performing a postdoctoral research fellowship at Stanford University. Michael T. George P. National Center for Biotechnology Information , U. Advances in Wound Care. Adv Wound Care New Rochelle.

Published online Feb 1. Boyko , 1,, 2 Michael T. Longaker , 1,, 3 and George P. Find articles by Tatiana V. Find articles by Michael T. Find articles by George P.

Author information Article notes Copyright and License information Disclaimer. Received Jun 7; Accepted Aug 5. Copyright , Mary Ann Liebert, Inc. This article has been cited by other articles in PMC. Abstract Significance: The incidence of pressure ulcers is increasing due to our aging population and the increase in the elderly living with disability.

Open in a separate window. Yang, MD, PhD. Scope and Significance T he fastest growing segment of our population is those over 65 years of age, and there are increased rates of obesity, diabetes, and cardiovascular disease. Translational Relevance Despite a number of new dressings and treatments available for the management of pressure ulcers, none has been demonstrated to have a significant benefit over the other.

Clinical Relevance The prevention and treatment of pressure ulcers are highly relevant to wound care professionals. Causation Pressure ulcers develop as a result of a combination of physiologic events and external conditions.

Figure 1. Table 1. Intrinsic and extrinsic factors influencing the development of pressure ulcers. Risk Assessment Assessing the risk for the development of pressure ulcers needs to be performed in all patients to institute appropriate prevention measures in those at risk.

Prevention Prevention of pressure ulcer formation is directed at alleviating the risk factors for the individual patient, and is primarily focused on minimizing episodes of prolonged pressure either by placing appropriate padding at pressure points or by frequent patient repositioning. Diagnosis and Assessment Once a pressure ulcer is identified, staging and careful documentation of the size of the wound should be performed.

Figure 2. Table 2. Table of different stages of pressure ulcers. Table 3. Pressure ulcer scale for healing PUSH tool. Treatment The mainstays of pressure ulcer treatment include offloading the offending pressure source, adequate drainage of any areas of infection, debridement of devitalized tissue, and regular wound care to support the healing process.

Pressure relief The first step in management is offloading pressure from the wound site. Infection control An important part of the initial evaluation of a pressure ulcer is to determine if there is evidence of inadequately treated infection. Debridement Debridement of devitalized tissue and biofilm and abscess drainage are necessary in the treatment of pressure ulcers.

Dressings and topical agents Dressings should be chosen depending on the wound being treated Table 4 and Fig. Figure 3. Table 4. Type of Dressing Advantages Disadvantages Ideal Wound Alginate dressings Absorbent, infrequent changes Expensive Infected wounds Foam dressings Absorbent, provides padding Expensive Infected wounds, fragile surrounding skin, Stage I and for prevention Gauze dressings Inexpensive, microdebridement Frequent changes Large complex wounds with exudate or biofilm Honey dressings Mild antibiotic Poor efficacy Stage II with mild infection Hydrocolloid dressings Absorbent Expensive Wounds with minimal discharge, Stage II and III Hydrogel dressings Hydrating Moves easily Dry or dehydrated wounds, uninfected granulating wounds Silver dressings Antibiotic Prevents epithelialization Infected wounds, remove once infection is cleared Transparent film dressing Barrier from bodily fluids, infrequent changes Not porous, can rip skin on removal Stage I, Stage II without exudate.

Gauze dressings The traditional wet-to-dry method of gauze dressing now has more limited use in the treatment of pressure ulcers. Alginate dressings Alginate is a very absorbent material that is ideal for use in wounds with moderate to high discharge. Foam dressings Foam dressings are made from polyurethane, a semipermeable material that can accommodate a medium to high amount of wound exudate and can be used in infected pressure ulcers.

Hydrocolloid dressings Hydrocolloid dressings are made of a foam or film polyurethane material and contain a gelatin- or sodium carboxymethylcellulose-based gel material, which gives it the ability to absorb some fluids. Silver-containing dressings Silver has bactericidal properties and dressings that are impregnated with silver are ideal for use in infected wounds.

Honey-containing dressings There are anecdotal reports of the use of honey in the treatment of wounds since antiquity. Transparent film dressings Transparent film dressings are used primarily to protect Stage I or II ulcers where the skin remains intact. Negative pressure wound therapy Negative pressure wound therapy NPWT consists of a foam dressing, which can be tailored to fit the patient's wound and is covered by a transparent film to enable creation of a vacuum in the wound when the foam is attached to a suction device via tubing.

Other therapies Biophysical treatments, including direct electric stimulation, pulsed electromagnetic field, and pulsed radio frequency energy, have been used to promote wound healing. Patient optimization In addition to treatment of the pressure ulcer itself, it is important to treat the overall patient as well.

Control of contamination By default, any open pressure ulcer is superficially contaminated with environmental flora. Surgery for reconstruction Although the majority of pressure ulcers will heal following debridement and conservative treatments outlined above, sometimes surgery will allow more rapid resolution of the ulcer. Summary Pressure ulcer prevention remains the most important step in the management of these wounds.

Author Disclosure and Ghostwriting No competing financial interests exist. About the Authors Tatiana V. References 1. The impact of the aging population on coronary heart disease in the United States. Am J Med ; — Weight change, body composition, and risk of mobility disability and mortality in older adults: a population-based cohort study. Human skin wounds: a major and snowballing threat to public health and the economy. A new pressure ulcer conceptual framework.

Chronic wound repair and healing in older adults: current status and future research. The prevalence of pressure ulcers in a tertiary care pediatric and adult hospital. Bluestein D, Javaheri A. Pressure ulcers: prevention, evaluation, and management.

Kosiak M. Etiology and pathology of ischemic ulcers. Prevention and rehabilitation of pressure ulcers. Decubitus ; 4 —62, 64, 66 passim [ PubMed ] [ Google Scholar ]. Walton-Geer PS. Prevention of pressure ulcers in the surgical patient.

Health Quality O. Pressure ulcer prevention: an evidence-based analysis. Comprehensive management of pressure ulcers in spinal cord injury: current concepts and future trends. Occurrence and predictors of pressure ulcers during primary in-patient spinal cord injury rehabilitation. Park-Lee E, Caffrey C. Guidelines need to be flexible for indi- The World Health Organization also recognized the im- vidualized implementation based on the status of the patient portance of ensuring that health care recommendations are and the clinical environment in which the care is delivered.

Unauthorized reproduction of this article is prohibited. Guideline objectives and major outcomes considered were also reviewed. Whether a cost Updating Guidelines analysis was performed was also considered.

This was done in preparation for the de- fying additional guideline characteristics and critical content velopment of collaborative international guidelines. Tables were developed using the guideline appraisal criteria Search Strategy itemized in Figure 1.

Through a series of phone conferences, A search was conducted for guidelines related to pressure the authors reached a common understanding of each cri- ulcer prevention and treatment. Seven sets of guidelines con- terion.

Each author was then assigned guidelines to review, taining recommendations for both prevention and treatment extracting data to complete the table for his or her respective were identified. Two guidelines contained all or some aspects guidelines. Data extraction for each guideline was then re- of prevention, but not treatment. Two guidelines addressed viewed for accuracy by one of the other authors.

Authors also treatment only. Other strategies included ment was included in each guideline Figures 2 and 3. This re- and contrast the methodological rigor involved in guideline view was restricted to guidelines written in or translated into development, the currency and comprehensiveness of sup- English.

The authors would welcome English translations porting evidence, and inclusion of critical content. Using a of other guidelines as they undertake international guide- modified Delphi technique, gaps in pressure ulcer prevention line development work. Only nonindustry—sponsored guide- and treatment guidelines were identified. A comprehensive body of knowledge existed in try of Health17; Paralyzed Veterans of America18; National the current guidelines but was determined to be timely only Institute for Clinical Excellence19; The University of Iowa to the date each guideline was published and the extent Gerontological Nursing Interventions Research Center20; of the review of literature completed.

Overall, the pressure the American Medical Directors Association21,22; the Wound ulcer guidelines were well conceptualized, organized, and Healing Society23; and the Australian Wound Management clinically grounded. This group of reviewers determined Association. Many of the guidelines referred to the AHRQ pre- Descriptive information extracted for each guideline in- vention and treatment guidelines, refining and extending cluded the year of development and year of last review, the recommendations based on current literature and the needs type of developing group, if the guidelines were adapted of special populations.

Special populations were included in the Para- lyzed Veterans of America guideline,18 focusing on persons with spinal cord injury, and the American Medical Directors Association guideline,21,22 focusing on older adults and residents of long-term-care facilities. Although most guide- lines provide broad recommendations that could be applied to multiple populations, there are some unique aspects of pressure ulcer prevention and treatment that should be investigated and developed for specialty populations, such as neonatal, pediatric, bariatric, geriatric, palliative care, and critical care patients.

Future guidelines should address the unique needs of these specialty populations. The qualified physician will be board certified in guidelines.