Common Questions About Pressure Ulcers

 


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Patients with limited mobility due to physical or cognitive impairment are at risk of pressure ulcers. Primary care physicians should examine at-risk patients because pressure ulcers are often missed in inpatient, outpatient, and long-term care settings. High-risk patients should use advanced static support surfaces to prevent pressure ulcers and air-fluidized beds to treat pressure ulcers. Physicians should document the size and clinical features of ulcers. Cleansing should be done with saline or tap water, while avoiding caustic agents, such as hydrogen peroxide. Dressings should promote a moist, but not wet, wound healing environment. The presence of infection is determined through clinical judgment; if uncertain, a tissue biopsy should be performed. New or worsening pain may indicate infection of a pressure ulcer. When treating patients with pressure ulcers, it is important to keep in mind the patient's psychological, behavioral, and cognitive status. The patient's social, financial, and caregiver resources, as well as goals and long-term prognosis, should also be considered in the treatment plan.

Pressure ulcers are injuries of the skin or underlying tissue that occur as a result of pressure alone or in combination with shearing forces. The ulcers typically occur over boney prominences.1 During pressure ulcer development, external pressure exceeds capillary blood flow pressure, leading to ischemia and tissue injury.2 Pressure ulcers are common, affecting up to 3 million Americans3 and costing about $11 billion annually in the United States.4 The most important risks for pressure ulcer development are impaired mobility, decreased perfusion, and edema or a stage I pressure ulcer.5 Additional risk factors include poor general health status, low nutritional status, and skin moisture from conditions such as incontinence.5 Advanced age and cognitive impairment are also risk factors.5 Multifactorial interventions to reduce pressure ulcers are among the top-10 strategies strongly encouraged by the Agency for Healthcare Research and Quality for adoption in all health care systems.6 When treating patients with pressure ulcers, it is important to keep in mind the patient's psychological, behavioral, and cognitive status. The patient's social, financial, and caregiver resources, as well as goals and long-term prognosis, should also be considered when developing a treatment plan.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Multicomponent interventions should be used to prevent pressure ulcers in high-risk patients.

B

7

Advanced static support surfaces, rather than standardized hospital mattresses, should be used to prevent pressure ulcers in high-risk patients.

A

3, 8, 9

Hydrocolloid or foam dressings should be used for the treatment of pressure ulcers.

B

4, 22

Cleansing pressure ulcers with caustic agents, such as povidone-iodine (Betadine) or Dakin's solutions, should be avoided.

C

23, 24

Air-fluidized beds should be used for the treatment of pressure ulcers.

A

4

New or worsening pain may indicate infection of a pressure ulcer.

C

32


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Multicomponent interventions should be used to prevent pressure ulcers in high-risk patients.

B

7

Advanced static support surfaces, rather than standardized hospital mattresses, should be used to prevent pressure ulcers in high-risk patients.

A

3, 8, 9

Hydrocolloid or foam dressings should be used for the treatment of pressure ulcers.

B

4, 22

Cleansing pressure ulcers with caustic agents, such as povidone-iodine (Betadine) or Dakin's solutions, should be avoided.

C

23, 24

Air-fluidized beds should be used for the treatment of pressure ulcers.

A

4

New or worsening pain may indicate infection of a pressure ulcer.

C

32


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

The Authors

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JAQUELINE G.M. RAETZ, MD, is an assistant professor in the Department of Family Medicine at the University of Washington in Seattle....

KEREN H. WICK, PhD, is an associate professor and director of research and graduate programs at the MEDEX Northwest Physician Assistant Program at the University of Washington.

Author disclosure: No relevant financial affiliations.

Address correspondence to Jaqueline G.M. Raetz, MD, University of Washington, 331 NE Thornton Place, Seattle, WA 98125 (e-mail: jraetz@uw.edu). Reprints are not available from the authors.

REFERENCES

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1. Haesler E, ed. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: quick reference guide. Perth, Australia: Cambridge Media; 2014. http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA.pdf. Accessed August 4, 2015....

2. Grey JE, Harding KG, Enoch S. Pressure ulcers. BMJ. 2006;332(7539):472–475.

3. Chou R, Dana T, Bougatsos C, et al. Pressure ulcer risk assessment and prevention: a systematic comparative effectiveness review. Ann Intern Med. 2013;159(1):28–38.

4. Smith ME, Totten A, Hickam DH, et al. Pressure ulcer treatment strategies: a systematic comparative effectiveness review. Ann Intern Med. 2013;159(1):39–50.

5. Coleman S, Gorecki C, Nelson EA, et al. Patient risk factors for pressure ulcer development: systematic review. Int J Nurs Stud. 2013;50(7):974–1003.

6. Shekelle PG, Pronovost PJ, Wachter RM, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med. 2013;158(5 pt 2):365–368.

7. Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 pt 2):410–416.

8. McInnes E, Jammali-Blasi A, Bell-Syer SE, Dumville JC, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev. 2011;(4):CD001735.

9. Qaseem A, Mir TP, Starkey M, Denberg TD. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015;162(5):359–369.

10. Gefen A. How much time does it take to get a pressure ulcer? Integrated evidence from human, animal, and in vitro studies. Ostomy Wound Manage. 2008;54(10):26–28,30–35.

11. Moore ZE, Cowman S. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database Syst Rev. 2014;(2):CD006471.

12. Moore ZE, Webster J. Dressings and topical agents for preventing pressure ulcers. Cochrane Database Syst Rev. 2013;(8):CD009362.

13. McGinnis E, Stubbs N. Pressure-relieving devices for treating heel pressure ulcers. Cochrane Database Syst Rev. 2014;(2):CD005485.

14. Gillespie BM, Chaboyer WP, McInnes E, Kent B, Whitty JA, Thalib L. Repositioning for pressure ulcer prevention in adults. Cochrane Database Syst Rev. 2014;(4):CD009958.

15. Whitney J, Phillips L, Aslam R, et al. Guidelines for the treatment of pressure ulcers. Wound Repair Regen. 2006;14(6):663–679.

16. Institute for Clinical Systems Improvement (ICSI). Pressure ulcer prevention and treatment protocol. Health care protocol. Bloomington, Minn.: Institute for Clinical Systems Improvement (ICSI); January 2012. http://www.guideline.gov/content.aspx?id=36059#Section420. Accessed August 4, 2015.

17. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA. 2006;296(8):974–984.

18. National Pressure Ulcer Advisory Panel. NPUAP pressure ulcer stages/categories. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/. Accessed August 4, 2015.

19. National Pressure Ulcer Advisory Panel. Pressure ulcer category/staging illustrations. http://www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-categorystaging-illustrations/. Accessed August 4, 2015.

20. Moore ZE, Cowman S. Wound cleansing for pressure ulcers. Cochrane Database Syst Rev. 2013;(3):CD004983.

21. Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012;(2):CD003861.

22. Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015;162(5):370–379.

23. Rodeheaver GT. Pressure ulcer debridement and cleansing: a review of current literature. Ostomy Wound Manage. 1999;45(1A suppl):80S–85S.

24. Lyder CH, Ayello EA. Pressure ulcers: a patient safety issue. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, Md.: Agency for Healthcare Research and Quality; 2008. http://www.ncbi.nlm.nih.gov/books/NBK2650/. Accessed August 4, 2015.

25. Kerstein MD, Gemmen E, van Rijswijk L, et al. Cost and cost effectiveness of venous and pressure ulcer protocols of care. Dis Manag Health Outcomes. 2001;9(11):651–663.

26. Kroshinksy D, Strazzula L. Pressure ulcers. Merk Manuals Professional Edition. March 2013. http://www.merckmanuals.com/professional/dermatologic-disorders/pressure-ulcers/pressure-ulcers/. Accessed August 4, 2015.

27. Dumville JC, Stubbs N, Keogh SJ, Walker RM, Liu Z. Hydrogel dressings for treating pressure ulcers. Cochrane Database Syst Rev. 2015;(2):CD011226.

28. Langer G, Fink A. Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database Syst Rev. 2014;(6):CD003216.

29. Moore ZE, Cowman S. Repositioning for treating pressure ulcers. Cochrane Database Syst Rev. 2015;(1):CD006898.

30. Kawasaki L, Mushahwar VK, Ho C, Dukelow SP, Chan LL, Chan KM. The mechanisms and evidence of efficacy of electrical stimulation for healing of pressure ulcer: a systematic review. Wound Repair Regen. 2014;22(2):161–173.

31. Chen C, Hou WH, Chan ES, Yeh ML, Lo HL. Phototherapy for treating pressure uclers. Cochrane Database Syst Rev. 2014;(7):CD009224.

32. Reddy M, Gill SS, Wu W, Kalkar SR, Rochon PA. Does this patient have an infection of a chronic wound? JAMA. 2012;307(6):605–611.

33. Pineda C, Vargas A, Rodríguez AV. Imaging of osteomyelitis: current concepts. Infect Dis Clin North Am. 2006;20(4):789–825.



 

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