PRESSURE ULCER MANAGEMENT

Pressure ulcer is the most prevalent health issue all around the world. For every 1,000,000 patients who developed Pressure ulcer 65,000 die from complications which presents a major challenge worldwide. Medical research is constantly striving to identify efficient ways for managing this long prevailing issue and reduce the fatality caused due to mismanagement of the pressure ulcers.

Lets understand a little about what exactly are these pressure ulcers, how are they formed and what are the current methods in practice for management of pressure ulcers.

What are Pressure Ulcers?

Pressure Ulcer commonly known as bed sore is an area on the body where there is damage to the skin & underlying tissue due to prolonged pressure, sheer, friction or a combination of all these.  

Fig1. Causes of  Pressure Ulcer Development

 

Pressure ulcers are commonly observed in the patients with decreased mobility like patients suffering with paralysis or the elderly. The ulcers can occur whenever the body has been in the same position for long duration causing loss of blood flow and skin thinning to the bony prominence area. Hence to maintain the blood flow pressure off loading is highly essential for immobile patients. Image below depicts the pressure points where the ulcers can surface if the body remains in that position for higher durations.

Fig2. Common Points subjected to pressure ulcer

  Along with the immobility of the patient there are certain other factors that cause the tissue more likely to become ischemic even under the same pressure these factors include presence of comorbities such as diabetes, multiple sclerosis, infection. Presence of any of these comorbities can minimize tissue strength with the ability of nervous system respond & to initiate the healing process of the wound.

Intrinsic contributing factors include:

·         Malnutrition

·         Dehydration

·         Impaired mobility

·         Chronic conditions

·         Impaired sensation

·         Decreased LOC

·         Infection

·         Advance age

·         Steroid use

·         Pressure ulcer present

External contributing factors include:

·         Pressure

·         Friction

·         Moisture

·         Incontinence

·         Shear

Stages of Pressure Ulcer

A pressure ulcer can range from a little discoloration of the skin to deep cavity wounds. According to Sullivan and Schoelles (2013), pressure ulcers occur in four stages. Similar to measurements of burn severity, each stage of pressure ulcer severity indicates a different depth and a new layer of tissue affected.

Fig3. Stages of Pressure Ulcer as per Sullivan and Schoelles

However National Pressure Injury advisory panel provides a slightly advanced classification for the pressure ulcers. These six stages are as follows.

Stage1: Non blanch-able erythma

Stage2: Partial thickness skin loss

Stage 3: Full thickness skin loss

Stage 4: Full thickness tissue loss

Stage 5: Unstageable – Depth unknown

Stage 6: Deep tissue injury Depth unknown

Fig4. Stages of Pressure Ulcer as per NPUAP

Fig5. Brief description for different stages of Pressure Ulcers

 

Pressure Ulcer Prevention

Pressure injuries can be prevented if acted upon timely; few general methods to be used are as below:

1.      Pressure Distribution- This can be done using pressure re-distribution surface, positioning devices, prophylactic dressings etc.

2.      Positioning devices- Pillows can be used for offloading the pressure points

3.      Avoid Sheer or friction – While repositioning the patient avoid causing friction or sheer to the skin

4.      Micro shifting – Perform Small repositioning of the patient, especially in case of non rotating beds

5.      Prophylactic dressings – Use of silicon based foam dressings can be very effective in preventing the wound from further injury

 

Wound Assessment

PUSH tool is widely used tool for assessing the pressure ulcers.

Nutritional Evaluation

Despite the consensus that adequate nutrition is important in wound healing, documentation of its effect on ulcer healing is limited; recommendations are based on observational evidence and expert opinion. Nutritional screening is part of the general evaluation of patients with pressure ulcers. In patients who are malnourished, dietary consultation is recommended and a swallowing evaluation should be considered. Intervention should include encouraging adequate dietary intake using the patient's favorite foods, mealtime assistance, and snacks throughout the day. High-calorie foods and supplements should be used to prevent malnutrition. If oral dietary intake is inadequate or impractical, enteral or parenteral feeding should be considered, if compatible with the patient's wishes, to achieve positive nitrogen balance (approximately 30 to 35 calories per kg per day and 1.25 to 1.5 g of protein per kg per day). Protein, vitamin C, and zinc supplements should be considered if intake is insufficient and deficiency is present,

Method for Pressure ulcer wound management

There are various options available for the management of the pressure ulcers. Depending on the wound stage the most suitable option can be selected for administration.

 

Fig6. Pressure ulcer management algorithm

Significance of Negative Pressure Wound Therapy in management of pressure ulcers

NPWT should be considered first line of defense in case of stage IV pressure ulcers and highly exudating stage III pressure ulcers. Using NPWT on deep pressure ulcers that are not responding to any other treatment can significantly promote wound healing.

Using NPWT has multiple benefits such as  

·         Stimulates growth of new granulation tissue

·         Angiogenesis

·         Reduction of edema

·         Sterile wound healing environment

·         Enhanced wound perfusion

·         Decreased bacterial contamination  

·         Decreased anaerobic activity

·         Reduces frequent dressing

·         Faster wound healing

·         Reduced healing time

·         Easy & early patient mobilization

·         Clean & exudates free wound management

·         Enhances patient’s quality of life

·         Reduced infection risk from patient to attendee & from hospital to patient

Treatment Goals with NPWT

 

·         Provide a temporary wound cover

·         Manage wound fluid and edema

·         Accelerate patient mobility

·         Improve pain management

·         Prevent wound progression

·         Increase dermal and wound perfusion

·         Stimulate formation of granulation tissue

 

·         Enhance wound bed epithelialization

·         Improve matrix material availability

·         Reduce bacterial load

·         Provide moist wound environment

·         Influence expression of genes involved in wound healing

However while choosing NPWT as method of treatment always consider the contraindication of NPWT is the presence of necrotic or fibrotic tissue, untreated osteomylytis, absence of appropriate blood supply etc.

NPWT is based on assumption that a uniform negative pressure event three-dimensionally creates tissue deformation and cell stretching, leading to metabolic activity and cell proliferation. The most common dressing material is the polyurethane foam sponge with a wide variation in the coarseness of the mesh. The PU foam sponge maintains suitable moisture, it is generally accepted that moisture balance is essential to all phase of wound healing exposed cells of the wound surface require surface moisture for viability while too little can cause cell death, exercise can cause maceration and damage to would edges and peri-wound skin.

Conclusion

Wound care clinicians have a wide array of treatment options available with which to manage and help heal pressure ulcers. Few of the methods have been discussed above however, the challenge is to determine the most appropriate treatment strategy while considering many factors regarding the wound, the patient, and the cost of care to ensure that assessments, treatment pathways, and product selections are both clinically and economically sound.