25th July 2023

Pressure Ulcers

Overview

A pressure ulcer is an area of erythema that can progress to the breakdown of the skin and underlying structures, such as the bone and muscle, to form an erosion or ulcer. It is due to persistent pressure, heat, friction, or a combination of both to the affected area. Prolonged periods of pressure reduce blood flow to the skin and underlying structures. It can develop in any area of the body, but mainly overlying bony prominences such as the sacrum. Risk factors include chronic conditions, immobility, moisture (incontinence), poor wound healing (malnutrition), urinary tract infections and stroke.

Assessment

Risk assessment tools such as Norton, Braden and the Waterlow scales can be used to identify patients at risk of developing pressure sores. When ulcers are assessed, it is important to check for local signs of infection. The classification system from the European Pressure Ulcer Advisory Panel Grading System is outlined below.

Table 2: European Pressure Ulcer Advisory Panel Grading System

Management

Pressure ulcers are difficult to heal, painful and can negatively impact the patient’s quality of life. Management includes good nutrition, appropriate wound management, adequate pressure distribution (suitable mattresses and repositioning) and analgesia. Key management points include:

• Moist wound environment encourages ulcer healing. Hydrocolloid dressings and hydrogels can help facilitate this. Discourage the use of soap as it can cause drying of the wound.
• Wound swabs are not routinely done as most pressure ulcers are colonised by commensal bacteria (polymicrobial).
• Decision to treat with systemic antibiotics is based on clinical judgement, i.e., spreading cellulitis, underlying osteomyelitis, clinical evidence of sepsis
• Consider referral to Tissue Viability Nurse (TVN).
• Surgical debridement may be beneficial for selected wounds.
• Do not routinely offer nutritional supplements to patients with adequate nutritional status to prevent pressure ulcers.