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Module 5.1: Pressure Ulcers/ Injuries

MANAGEMENT OF PRESSURE INJURIES

The underlying pathology of a pressure ulcer/injury must be treated. Pressure must be relieved or removed by appropriate measures to prevent further injury, ensure the patient is receiving adequate nutrition and that wound care is optimised. The key concepts of pressure ulcer/injury management are discussed below.

Ensuring that pressure ulcers/injuries are prevented using a risk assessment, early detection through regular skin inspection and appropriate prophylaxis is essential.

The following preventative care interventions are recommended in the case of pressure ulcers/injuries:

  • Skin inspection
  • Repositioning
  • Use of relieving/reducing equipment
  • Skin care, clean, dry and hydrated
  • Management of incontinence and excess moisture
  • Maintaining adequate dietary and fluid intake

(Wilson, 2012)

Successful pressure ulcer management requires a comprehensive approach that includes prevention, relieving pressure, restoring circulation, managing the wound and minimising related disorders.

Dressing Selection

Most guidelines recommend the use of wound care dressings for the treatment of pressure ulcers/injuries and should provide a moist wound healing environment.

For all pressure injuries, dressing selection should be the most appropriate, based on goals and self-care abilities of the individual and/or their caregiver and based on clinical assessment, including:

  • Width, shape, and depth of the pressure injury
  • Need to address bacterial bioburden
  • Ability to keep the wound bed moist
  • Type and volume of wound exudate
  • Condition of the tissue in the wound bed
  • Condition of the periwound skin
  • Presence of tunnelling and/or undermining
  • Pain
  • Frequency of dressing changes

EPUAP, 2019

Please see Module Five Dressing Selection.

The treatment needs of a pressure ulcer/injury change over time. Treatment strategies should be continuously re-evaluated based on the status of the ulcer.

Nutrition

Good nutrition is essential for pressure ulcer/injury prevention and management. Patients should be screened and their nutritional status assessed. It is important to encourage liquid intake, as hydration is as important as nutrition.

Patients with pressure ulcers/injuries may require a greater proportion of protein in their diet to help ensure a positive nitrogen balance and replace protein lost through their ulcers. They may also need vitamin and trace element supplementation (Hess, 2002). (Also see patient assessment section, module 3, section two).

Reassessment of Risk and Grading

Risk monitoring and grading of pressure ulcers/injuries should be reassessed at regular intervals to make sure that patient management plans (equipment selection) are appropriate.

Patient Education

The goal of patient education is to improve the possibility of pressure ulcer/injury prevention. Patients should be involved in the assessment, prevention and treatment of their condition/wound. Knowledge and understanding can play a major part in patients’ compliance with their treatment regimes. Patients who are willing and able should be taught how to relieve their own pressure areas to aid in pressure ulcer/injury prevention and management (Vuolo, 2009).

The information to the patient/carer should include:

  • The cause of a pressure ulcer/injury
  • The early signs of a pressure ulcer/injury
  • Ways to prevent a pressure ulcer/injury
  • Implications of having a pressure ulcer/injury (for general health, treatment, options and future development risks)
  • Techniques and equipment

If patients refuse to allow a change in position, it may be necessary to consider their mental capacity, which must be officially assessed and documented. Also, patients must be made aware that their choice may have a direct impact on pressure ulcer development. This must be clearly documented in the individual’s medical and nursing notes.

Moisture

Prolonged exposure to moisture can waterlog the skin, leaving it macerated. This softens the connective tissue and may lead to an increased risk of pressure ulcer development (Wilson, 2012). Factors of excessive perspiration, oedema and incontinence may place the patient at risk of skin damage from excess moisture.

Incontinence

In urinary incontinence, the urea contained in urine decomposes the skin, resulting in the formation of ammonium hydroxide, which will raise the pH level of the skin, encouraging bacterial proliferation (Errsser et al., 2005). In faecal incontinence, enzymes such as proteases and lipases degrade the barrier function of the skin, which allows microorganisms to proliferate and facilitates bacterial and fungal growth (Wilson, 2012).

End of Life

Skin changes at the end of life may be an inevitable event that will not be avoided despite all preventative measures being implemented (Galvin, 2002). The skin is an organ, like the heart, and is subject to failure. This is most likely to occur at the end of life and may result in unavoidable skin damage (Bedfordshire & Hertfordshire TVN Forum, 2010).

The information given in this section is a guide, and practitioners must ensure they refer to both local and national guidelines when treating patients who have pressure ulcers/injuries or those at risk of pressure ulcer/injury development.

View the module references