Pressure ulcersMussa MensaCT2 The Welsh Centre for Burns and Plastic Surgery

Introduction•Localised skin and underlying tissues

damaged due to prolonged pressure sufficient to impair blood supply

•Typically occur in a person confined to bed or a chair by an illness

•Develop quickly•All patients are potentially at risk

Introduction•Cost the NHS an estimated £1.8-2.6

billion a year1

•2-4% of health expenditure 1,2

•Pressure ulcers are (potentially) preventable

5 Key PointsEarly recognition of people who are

at risk of developing

pressure ulcers is an essential part

of prevention

Risks are most often assessed using specific

tools

Ulcers/Sores should be

assessed, graded and recorded/ documented

Adequate pressure redistribution,

appropriate wound management and good nutrition are

key to management

The majority of pressure ulcers

can be prevented

Risk factors

pressure on bony prominence

reduced/occluded blood flowmovement

tissue hypoxia pain

tissue necrosis/ ulceration

reduces

Risk factorsPatient factors

•Serious illness•Neurological condition•Impaired mobility•Impaired nutrition•Poor posture/deformity

• Alzheimer’s• Cardiovascular disease• Diabetes mellitus• COPD• Hip fracture/ hip surgery• Heart failure• DVT• Limb paralysis • Lower limb oedema• Malignancy• Parkinson’s disease• Rheumatoid arthritis • Urinary tract infections

Environmental factors•Seating & beds that do not provide pressure relief

Risk assessment•Identify individuals at risk – initial + ongoing•Most common assessment tools:

•*No evidence to suggest use of risk assessment tools reduces incidence

Risk assessment tool SpecialtyWaterlow (Waterlow 2005) Orthopaedic/ GenericBraden (Bergstrom et al, 1987) GenericNorton (Norton 1975) Older people/GenericMortenson/Gelis (Mortenson et al 2008, Gelis et al, 2009)

Spinal cord injury

Glamorgan (Willock et al, 2009) Paediatric

Risk assessment

•Most common assessment tools:Risk assessment tool SpecialtyWaterlow (Waterlow 2005) Orthopaedic/ GenericBraden (Bergstrom et al, 1987) Generic

Norton (Norton 1975) Older people/Generic

Mortenson/Gelis (Mortenson et al 2008, Gelis et al, 2009)

Spinal cord injury

Glamorgan (Willock et al, 2009) Paediatric

Risk assessment

•Most common assessment tools:Risk assessment tool SpecialtyWaterlow (Waterlow 2005) Orthopaedic/ Generic

Braden (Bergstrom et al, 1987) GenericNorton (Norton 1975) Older people/GenericMortenson/Gelis (Mortenson et al 2008, Gelis et al, 2009)

Spinal cord injury

Glamorgan (Willock et al, 2009) Paediatric

Risk assessment

•Most common assessment tools:Risk assessment tool SpecialtyWaterlow (Waterlow 2005) Orthopaedic/

GenericBraden (Bergstrom et al, 1987) GenericNorton (Norton 1975) Older people/GenericMortenson/Gelis (Mortenson et al 2008, Gelis et al, 2009)

Spinal cord injury

Glamorgan (Willock et al, 2009) Paediatric

Ulcer assessment•Should be supported by photography (calibrated with a ruler) and tracings •Include:

•Reassessment of the ulcer should be performed at least weekly

• Cause of ulcer• Site/ Location• Dimensions• Stage/Grade• Wound appearance

• Surrounding skin• Local signs of infection• Pain• Exudate amount + type• Odour

Ulcer grading/classification •European Pressure Ulcer Advisory Panel

grading system4

Ulcer grading/classification •European Pressure Ulcer Advisory Panel

grading system•Grade 1:

▫non-blanchable erythema of intact skin▫discolouration of the skin, warmth,

oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin - in whom it may appear blue or purple

Ulcer grading/classification •European Pressure Ulcer Advisory Panel

grading system•Grade 2:

▫partial-thickness skin loss involving epidermis, dermis, or both

▫the ulcer is superficial and presents clinically as an abrasion or blister

▫surrounding skin may be red or purple

Ulcer grading/classification •European Pressure Ulcer Advisory Panel

grading system•Grade 3:

▫full-thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia

Ulcer grading/classification •European Pressure Ulcer Advisory Panel

grading system•Grade 4:

▫extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, with or without full-thickness skin loss

▫extremely difficult to heal and predispose to fatal infection

Management•Goals -  achieve a healthy wound bed and

promote healing

Key factors in ulcer healing:1.Adequate pressure redistribution2.Good nutrition3.Appropriate wound management

ManagementPrinciples:•Repositioning•Pressure relieving support•Local wound management – dressings/VAC•Treatment of concurrent conditions delaying wound healing•Pain relief•Infection control•Dietary supplementation

Management•Debridement:

▫Autolytic – occlusive dressings

▫Mechanical – during dressing changes

▫Surgical – for deep ulcers not responding to standard care

Prevention•The majority of pressure ulcers can be

prevented:▫Education and training

▫Reduce skin injury through correct positioning, transferring and repositioning

▫Reduce underlying risk factors e.g. nutrition

▫Pressure redistributing equipment should be used

Prevention▫Emollients for dry skin

▫Barrier preparations to prevent skin damage in those at high risk of developing a moisture lesion or incontinence-associated dermatitis

▫Polyurethane foam dressing can be applied to bony prominences

Thank you for listening!

References1. Mahalingam S, Gao L, Nageshwaran S, et al;

Improving pressure ulcer risk assessment and management using the Waterlow scale at a London teaching hospital. J Wound Care. 2014 Dec;23(12):613-22. doi: 10.12968/jowc.2014.23.12.613.

2. Posnett J, Franks P (2007) The costs of skin breakdown and ulceration in the UK. In: Pownall M (ed) Skin Breakdown: the Silent Epidemic. London: Smith & Nephew

3. Pressure ulcers; NICE Quality Standard, June 2015 4. Treatment of Pressure Ulcers: Quick Reference

Guide; National Pressure Ulcer Advisory Panel, 2014