Clinical Care Treatment Protocols, Pressure Ulcer

What is a pressure ulcer?

A pressure ulcer is a break in the integument in the trochanteric, ischial, heel, and sacral areas, usually caused by continuous pressure to skin and muscle. Although they can potentially occur anywhere on the body, pressure ulcers are rare in other areas.

What is the prevalence of pressure ulcers?

The prevalence of pressure ulcers in the United States has been estimated to be at least 1.7 million. Pressure ulcers are an epidemic among bed-bound populations, with an estimated prevalence of:

• 17% among hospitalized patients
• At least 13% among patients in nursing homes
• Up to 38% among patients with spinal cord injuries

What is the prevalence of pressure ulcers in patients
with spinal cord injuries?

At any point in time, it is estimated that up to 38% of spinal cord injured patients have a pressure ulcer. Patients with spinal cord injuries are particularly susceptible to developing pressure ulcers. An inability to move in response to pressure may be due to an impaired angiogenic response.

Who is at high risk to develop a pressure ulcer?

Any bed-bound patient is at risk for developing a pressure ulcer. Pressure ulcers often develop in patients not immediately aware of the wound's presence, such as paralyzed patients and elderly patients undergoing treatment for other diseases. Every patient with limited mobility is at risk.

How do pressure ulcers affect hospitalization?

It is estimated that a new pressure ulcer can increase a patient's hospital stay by nearly a factor of five.

Are patients with pressure ulcers at more risk for increased morbidities and mortalities?

Pressure ulcers are associated with increased morbidity and mortality. Independent of the source of the ulcer, evidence shows that patients with pressure ulcers have a mortality rate twice as high as those without pressure ulcers.

How are patients affected by cost?

In assessing the total cost of pressure ulcers, it is important to consider the costs of non-treatment. For example, a small ulcer in a critically ill patient is generally not considered to be a significant clinical problem.

A retrospective analysis of more than 1,000 patients studied the cost of treatment for 19 patients with stage IV pressure ulcers. Each patient required hundreds of thousands of dollars in additional treatments for complications from their stage IV ulcers—including treatment for sepsis, renal dialysis, and respiratory therapy. Treatment of the ulcer itself is not costly compared to the cost of treating the ensuing complications. Early recognition and treatment of pressure ulcers is therefore mandatory to minimize costs, as well as to prevent progression and to accelerate healing. Xakellis and his team, for instance, showed that the cost of treating stage IV ulcers is 10 times that of treating stage II ulcers.

What is the most essential aspect of treating a pressure ulcer?

The most important component of pressure ulcer care is daily examination of the pelvic, sacral, and heel areas. Any break in the skin is an emergent situation. It must be immediately documented and a plan should be initiated. Early recognition and intervention are vital to successful treatment.

Why daily inspections?

Daily documentation of subsequent ulcer changes (e.g., measurement of contraction and epithelialization) must be maintained to ensure appropriate treatment and prevent the ulcer from progressing to Stage IV. Bed-bound patients can develop pressure ulcers in less than two hours; daily inspections are vital in preventing their progression.

Which areas should be inspected?

The areas at high risk of developing pressure ulcers are the ischial, sacral, trochanteric, and heel areas.

How are pressure ulcers characterized?

Pressure ulcers are characterized by four stages:

What should be assessed during documentation?

IIt is mandatory that a full evaluation of the ulcer be performed at least once a week—measuring length, width, depth, cellulitis, presence of drainage, and undermining. It is essential to evaluate every patient for pain and reevaluate to determine if the pain is resolved. This may be particularly challenging in an elderly patient on a ventilator, but nevertheless it is mandatory care.

It is mandatory to have an objective measurement of the patient. s wound in the chart upon presentation, and weekly with follow-up. Utilizing a ruler is a minimal requirement. However, we urge photography and ideally planimetry.

Why is planimetry favorable?

The recording of these quantitative measurements reduces errors that may result from qualitative assessment and notation. A wound that "looks good" may nevertheless be failing to contract, epithelialize, or close in a timely manner. It may also be progressing towards osteomyelitis or be the source of fever or sepsis.

Is nutrition an important factor in healing pressure ulcers?

Nutrition should be maximized in every wound patient for a variety of reasons. Therefore, nutritional support should be aggressively evaluated and managed by a specialist, e.g., a clinical dietician, as soon as an ulcer is detected.

How should nutrition be monitored?

Prealbumin and albumin levels as well as body weight measurements should be taken regularly to ensure maintenance of proper nutrition.

What should be done if a person is malnourished?

Individualized diets should be created for each patient. Before patients leave the hospital or the care of their health providers, they should be educated on how to assess and maintain their nutritional health. If a patient enters the hospital in a malnourished state, an aggressive regimen must be implemented.

What type of pressure relief should be established for a patient with a pressure ulcer?

Pressure relief beds play a major role in reducing overall costs by preventing pressure ulcer progression. It is not currently known which bed is "ideal," but there are two factors to consider when determining the best bed surface: pressure relief and blood flow. The selection of a bed surface is an integral component of a wound care regimen and a crucial part of the wound healing armamentarium.

Ultimately, the goal of tissue load management is to develop an environment that enhances the viability of soft tissues and promotes healing. In addition to the vigilant use of proper positioning techniques, support surfaces designed to decrease pressure, friction, and shear while providing adequate levels of moisture and temperature to support tissue health and growth should also be utilized.

It is essential that every patient with even the smallest interruption in skin integrity start physical therapy, be moved out of bed (even if only into a chair with an adequate offloading cushion), and be given the best pressure relief system available in a particular setting.

How should patients with palliative care be treated?

Patients receiving palliative care are of special concern in terms of wound healing. Dr. J. Galvin found that 78.4% of pressure ulcers in palliative care patients occur in the sacral area—which is contrary to the common belief that most pressure ulcers occur in the trochanteric area. Even if a person is dying, debridement and stimulation in healing may result in dramatically decreased pain. Many patients who present to an intensive care unit may have sepsis from their wound.

It is important to have a discussion with the intensivist and of course with the family members to design a care plan for the patients. Sometimes the most amount of comfort you can provide a patient comes from removing the gangrenous tissue in their bone. In other circumstances, comfort and sedation is all that is necessary. However, at those times the proper place for that patient is not in an intensive care unit.