Pressure ulcers, otherwise known as decubitus ulcers, comprise a significant portion of wounds requiring specialized care and presenting additional costs, so prevention is critically important. A pressure ulcer is any lesion caused by unrelieved pressure resulting in damage of underlying tissue. Pressure ulcers usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed. Stage 1 pressure ulcers are defined as nonblanchable erythema of intact skin — the heralding lesion of skin ulceration. Stage 2 is defined as partial thickness skin loss involving epidermis and/or dermis; Stage 3 as full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; and Stage 4 as full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures.
The Wound, Ostomy and Continence Nurses Society (WOCN) says that pressure ulcer prevention is best accomplished by identifying patients who are at risk for the development of pressure ulcers and initiating early preventive measures. According to the WOCN, “This requires an understanding of risk factors, the utilization of research-based risk assessment tools, knowledge of appropriate preventive strategies and access to essential medical equipment such as therapeutic support surfaces.”
Patients who have already developed pressure ulcers require assessment and interventions to identify and correct the causative factor(s) and treatment modalities to assure optimal wound healing. Regular follow-up assessment and modifications of the treatment plan when indicated are also necessary to assure optimal wound repair and efficient use of resources, including supplies.
The difference between colonization and infection of wounds is decided by the concentration of organisms in the wound; an infected wound contains a larger number of microorganisms than a contaminated wound. According to clinical guidelines from the Agency for Healthcare Research and Quality (AHRQ), stage 2, 3 and 4 pressure ulcers should all be considered as colonized with bacteria. Proper wound cleansing and debridement should prevent bacterial colonization from proceeding to the point of clinical infection.
Strategies to manage pressure ulcers and facilitate healing include proper tissue load management (which includes proper positioning and the use of support surfaces) as well as appropriate ulcer care and management of infection.
Initial ulcer care involves debridement, wound cleansing, dressing application and possible adjunctive therapy. Debridement should be performed to remove moist, devitalized tissue. Small wounds can be debrided at bedside, while extensive wounds should be debrided in the operating room or special procedure room. Regarding wound cleansing, experts say that the benefits of cleaning should be weighed against the risk of potential trauma to the tissue bed caused by the cleaning. Solutions such as povidone iodine, iodophor, sodium hypochlorite solution, hydrogen peroxide and acetic acid should not be used because they are potentially cytotoxic. Use normal saline at a pressure between 4 and 15 pounds per square inch (psi). Regarding ulcer dressings, an ideal dressing should protect the wound, be biocompatible, and provide ideal hydration. The cardinal rule is to keep the ulcer tissue moist and the surrounding intact skin dry.
When caring for wounds, sterile instruments and clean dressings must be used. It is advisable to treat the most contaminated ulcer last in patients with multiple wounds. To prevent cross-contamination and the spread of infectious materials it is imperative for clinicians to wear the appropriate personal protective equipment (PPE), as well as change their gloves and perform thorough and proper hand hygiene in between patients.
