Photo Essay: A Pictorial Guide to Pressure Ulcers

Pressure ulcers occur frequently in elderly, hospice, and spinal cord injury patients. They affect 5% to 10% of patients in all health care facilities and add substantially to health care expenses.¹ The average cost of treatment ranges from $20,000 to $70,000, depending on the stage of the ulcer.²

The National Pressure Ulcer Advisory Panel defines a pressure ulcer as an injury caused by unrelieved pressure on a specific region of skin and muscle--usually a bony prominence--in bed- or chair-bound patients.² The prolonged pressure decreases blood supply to the affected area; this leads to hypoxia and ultimately ischemia, cell death, and tissue necrosis.

Generally, subcutaneous tissues are injured before the epidermis is affected; thus, an open wound represents "the tip of the iceberg."Palpation can detect induration, which indicates damaged subcutaneous tissue. Other features to assess during the examination of a pressure ulcer are:

•Location: Be specific, and draw pictures if necessary.

•Size: Measure the length, width, and depth of the ulcer; determine the length and location of the deepest tract, if necessary; and document any undermining of tissue. Record all measurements in centimeters.

•Character of wound: Describe the kind of tissue in the wound, ie, granulation tissue (Figure 1), yellow exudative tissue (Figure 2), or eschar (Figure 3). Note any discharge.

Risk factors for pressure ulcers include loss of functional independence, smoking, alcohol consumption, urinary and fecal incontinence, and poor nutrition. Poor care or neglect in hospitals and nursing homes also contributes to the development of pressure ulcers.

Complications include cellulitis, sepsis, autonomic dysreflexia (a syndrome of hypertension, flushing, and sweating in spinal cord injury patients), and pain. Two thirds of stage II or higher-stage pressure ulcers cause pain.¹

Rarely, chronic pressure ulcers can become malignant. Consider biopsy in chronic stage II or higher-stage ulcers (Figure 4) or when an ulcer has persisted for more than 5 years with little change. Squamous cell carcinoma is the most common cancer associated with chronic pressure ulcers.

Order a laboratory workup, including a white blood cell count, an erythrocyte sedimentation rate (ESR), and C-reactive protein measurement, for patients with stage III or IV ulcers. The ESR and C-reactive protein level decrease as the ulcer resolves. In patients with stage IV ulcers, obtain radiographs or MRI studies to rule out osteomyelitis. If osteomyelitis is present, intravenous antibiotic therapy is necessary to facilitate wound healing.

The best treatment for pressure ulcers is prevention. This can be accomplished with frequent inspection of skin and regular hygiene. Current guidelines recommend turning patients every 2 hours to prevent the development of pressure ulcers over the sacrum and coccyx.³ For patients who are functionally dependent (unable to ambulate or perform pressure relief without assistance), using cushioned boots or placing a pillow under the lower extremities prevents their heels from resting directly on the bed or wheelchair surface.

A healthful diet with adequate nutrition must be maintained. Albumin levels should be consistently higher than 3 g/dL to preserve the integrity of the skin. Measure albumin levels weekly in patients with spinal cord injury and in functionally dependent persons.

Treatment varies according to the stage of the pressure ulcer (Table)⁴:

•Stage I pressure ulcers require removal of the aggravating factors (eg, pressure and frictional forces). This may involve protection of the skin, elevation of the affected area, or frequent turning of the patient.

•Stage II pressure ulcers (Figure 5) can be treated with a hydrocolloid dressing, changed every 2 to 4 days, or topical antibiotic and sterile gauze dressing, changed daily.

•Stage III and stage IV pressure ulcers (Figures 6 and 7) frequently need manual debridement in addition to a wet-to-dry dressing changed daily. Enzymatic ointment is used when the base of the ulcer has yellow exudate and when manual debridement fails to remove all the damaged tissue. The ointment must be applied carefully because it can destroy normal tissue along with damaged or necrotic tissue.

Doughnut cushions are contraindicated for the treatment of pressure ulcers, regardless of stage. These cushions do not relieve the pressure; they simply change its location.