Treating a pressure ulcer is a complex task, healthcare professionals need to attempt to heal the wound whilst preventing further damage being done. This is especially difficult if the patient has restricted mobility or is immobile.

  • What are Pressure Ulcers?
  • How are Pressure Ulcers Assessed?
  • Causes of Pressure Ulcers
  • Treatment of Pressure Ulcers

    • Treatment usually has a number of the following components-

    Dressings

    The NICE guidance divides dressings into five basic categories:

    1. Contact layers. The key features of a contact layer should be their ability to prevent adherence the wound bed and allow free drainage of wound exudate (material exuded by the wound) These materials tend to be used on superficial or lightly exuding wounds - for example paraffin guaze, knitted viscose, silicone-coated fabric dressings.
    2. Passive dressings. Dressings that create a local wound environment conducive to healing by controlling the local wound environment but which do not change their physical state or directly modify or interfere with the physiology of the wound. Such dressings are commonly used to control exudate but they may also be used, for example, to prevent contamination or control odour. Examples include films, foams and hydrogels.
    3. Interactive dressings.Dessings that change their physical state in contact with wound exudate. Such products commonly form a gel-like covering on the wound surface that is claimed to promote healing. Examples include hydrocolloids, alginates and products containing carboxymethylcellulose fibre.
    4. Active Dressings.Products that aim to directly influence the physiology or biochemistry of the wound healing process. They include:
      • Products containing physiologically active components that act at a biochemical level in the wound bed. Typically influencing cell growth or correcting chemical deficits - for example growth factors, collagen and hyaluronic acid.
      • Skin grafts - the transplanting of human or animal skin on to a wound bed. May be patient's own (autograft) or animal - usually pig (Xenograft).
      • Tissue-engineered products.
      • Also known as skin substitutes or skin replacements. Products that replicate a layer (or layers) of human skin.
    5. Antimicrobial Dressings. Contain antimicrobial agents - for example iodine, chlorhexidine, sliver and honey.

    The guidance makes the following recommendations with regard to dressings:

    1. Choice of dressings or topical agents for the treatment of pressure ulcers should be based on:
      • ulcer assessment (condition of wound)
      • general skin assessment
      • treatment objective
      • dressing characteristics
      • previous positive effect of a particular dressing
      • manufacturer's indications for use and contraindications
      • risk of advers events
      • patient preference (lifestyle, abilities and comfort).
    2. There is insufficient research evidence to guide clinicians’ decision making about which dressings are most effective in pressure ulcer management. However professional consensus recommends: Create the optimum wound healing environment by using modern dressings – (e.g. hydrocolloids, hydrogels, hydrofibres, foams, films, alginates, soft silicones) in preference to basic dressing types – e.g. gauze, paraffin gauze and simple dressing pads.

    Debridement

    Debridement is a process which removes dead tissue or other debris from the wound. Many of the techniques available for wound debridement are easy to apply and may also have properties that are beneficial for wound healing. In current practice there is wide variation in the use of debriding agents and no consensus on which agent is most apppropriate for use with prssure ulcers.

    The guidance makes the following recommendation with regard to debridement -

    Clinicians should recognise the positive potential benefit of debridement in the management of pressure ulcers. Decisions about the method of debridement should be based on:

    Support Surfaces

    Support surfaces aim to reduce either the magnitude or the duration of pressure between the patient and the support surface. They include cushions, mattress overlays, replacement mattresses or whole bed replacements.

    There are two main types of surfaces: continuous low pressure (CLP) and altenating pressure (AP).

    CLP surfaces mould around the shape of the patient to redistribute pressure over a greater surface area whereas AP surfaces mechanically vary the pressure beneath the indvidual, so reducing the duration of the applied pressure.

    The guidance makes the following recommendations with regard to support surfaces:

    1. Patients with pressure ulcers should have access to appropriate pressure relieving support surfaces and strategies – for example mattresses, cushions, and repositioning – 24 hours a day and this applies to all support surfaces;
    2. Initial choice and subsequent decisions, following re-assessments, related to the provision of pressure-relieving support surfaces for patients with pressure ulcers should be based on:
      • ulcer assessment (severity);
      • level of risk: from holistic assessment;
      • location and cause of the pressure ulcer;
      • general skin assessment
      • general health status;
      • acceptability and comfort for the patient;
      • lifestyle of the patient;
      • ability of the patient to reposition themselves;
      • availability of carer/health professional to reposition the patient;
      • cost consideration.
    3. There is no conclusive research evidence that any one pressure-relieving support technology is superior to another. However professional consensus recommends that:
      • all individuals assessed as having a grade 1-2 pressure ulcer should, as a minimum provision, be placed on a high-specification foam mattress or cushion with pressure-reducing properties combined with very close observation of skin changes, and a documented positioning and repositioning regime.
      • if there is any perceived or actual deterioration of affected areas or further pressure ulcer development, an AP (replacement or overlay) or sophisticated CLP system – for example low air loss, air fluidised, air flotation, viscous fluid – should be used. N.B. For individuals requiring bed rails, AP overlay mattresses should be placed on a reduced-depth foam mattress to maintain safety.
      • individuals assessed as having grade 3-4 pressure ulcers (including intact eschar where depth, and therefore grade, cannot be assessed) should, as a minimum provision, be placed on an AP mattress (replacement or overlay) or sophisticated CLP system – for example low air loss, air fluidised, viscous fluid.
      • if alternating pressure equipment is required the first choice should be an overlay system, unless other circumstances such as patient weight or patient safety indicate the need for a replacement system. N.B. To ensure maximum effect the inflated cells of the overlay must support the body weight of the patient in all bed positions (during use of backrest, knee break) and all patient positions (sitting up, side lying).

    Positioning and Re-positioning

    Re-posistioning patients in order to reduce pressure on the wound is seen as a central part of the healing process. Both seated and bed-bound individuals are at risk of delayed healing yet there is no consensus as to how frequently people should be re-positioned. The NICE guidance authors were unable to locate any published studies that looked at the effecitveness of repositioning techniques. They do note that the literature reports a range of re-positioning times from every 2 to every 6 hours. Nevertheless, the guidance puts forward the following "consensus" recommendations:

    1. Mobilising, positioning and repositioning interventions should be considered for all individuals with pressure ulcers (including those in beds, chairs and wheelchairs).
    2. All patients with pressure ulcers should actively mobilise, change their position or be re-positioned frequently.
    3. Avoid positioning individuals directly on pressure ulcers or bony prominences (commonly the sites of pressure ulcer development).
    4. Mobilising, positioning and re-positioning interventions should be determined by:
      • general heath status;
      • location of ulcer;
      • general skin assessment;
      • acceptability (including comfort) to the patient;
      • the needs of the carer;
    5. Frequency of re-positioning should be determined by the patient’s individual needs and recorded.
    6. Passive movements should be considered for patients with pressure ulcers who have compromised mobility.

    Surgery

    According to the NICE guidance surgery may be considered:

    Surgery is not usually used on patients who have a grade one or two pressure ulcer - it is used as an intervention on people with a grade three or four pressure ulcer.

    Complications arising from surgery could be any of the following:

    The guidance makes the following recommendation with regard to surgery on pressure ulcers-

    Referral for surgical interventions for patients with pressure ulcers should be based on:

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