Overview
Pressure ulcers describe localised skin and/or underlying tissue damage due to pressure or in combination with shear. They usually occur over bony prominences or may be due to medical devices or other objects. The damage caused by pressure ulcers can vary from small superficial lesions to extensive wounds that involve bone and necrosis.
They are commonly faced by hospital inpatients and people living in care facilities. Older people, people with impaired sensation, and people who are less mobile have a higher risk of developing them.
Pressure ulcers can be categorised using the NPUAP–EPUAP Pressure Ulcer Classification System.
The risk of developing a pressure ulcer is assessed using the Waterlow scale.
Epidemiology
- Prevalence increases with age, over 60% occur in people >70 years old
- More common in inpatients
- More common in patients who are less mobile
Risk Factors
- History of previous pressure ulcers
- Immobility
- Impaired sensation e.g. secondary to diabetes mellitus
- Surgery
- Intensive care admission
- Older age
- Peripheral arterial disease
- Poor nutrition
Presentation
- Pressure ulcers tend to be over sites that experience pressure (e.g. bony prominences)
- There may be non-blanching erythema
- They may present as wounds over sites that are known or suspected to have previously been exposed to pressure
Differential Diagnoses
Arterial ulcers
- Patients have a history of peripheral vascular disease
- Patients may hang their legs over the bed for relief
- Ulcers are painful, look punched-out, and are well-demarcated
- Ulcers usually seen on feet, heels, or toes
Venous ulcers
- Usually seen near ankles
- Often skin changes such as darkening and lipodermatosclerosis are present
- May or may not be painful
Osteomyelitis
- Bone pain, tenderness and swelling present
- The bone may be exposed in pressure ulcers, therefore osteomyelitis must be excluded in these scenarios
Pyoderma gangrenosum
- Usually associated with inflammatory conditions e.g. inflammatory bowel disease
- Usually start as a small area and enlarges rapidly
- Usually develop at sites of trauma
Neuropathic ulcers
- History of diabetes mellitus may be present
- No pain
- Usually on toes, heels, or other weight-bearing parts of the feet
Investigations
Pressure ulcers are a clinical diagnosis. Other investigations may need to be considered to rule out other conditions:
- Wound swab and culture if signs of infection are present:
- These are not very useful as often the cultures show bacteria that have colonised the wound and skin rather than the infective agent itself.
- Full blood count (FBC) and white cell differential:
- May show leukocytosis suggesting infection/osteomyelitis
- Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP):
- May be raised suggesting infection/osteomyelitis
- Blood glucose:
- To screen for diabetes mellitus
- MRI:
- To screen for osteomyelitis
Management
Patients should immediately be relieved of pressure and given skin care along with hydrocolloid dressings to promote healing
If there is necrotic tissue, antibiotics are given:
- If there is no response to antibiotics, then an MRI should be carried out to rule out osteomyelitis
- Surgical debridement of the wound may be needed.
Monitoring
- Patients who are at risk of developing pressure ulcers should be monitored daily to assess for signs of pressure ulcers
- Patients should also be repositioned when possible. This is often done every 2 hours.
Patient Advice
- Patients should be educated on the importance of regular repositioning, checking their skin or having their skin checked, and be safety-netted on recognising signs of pressure ulcers forming.
Complications
- Cellulitis
- Osteomyelitis
- Sepsis
Prognosis
- Pressure ulcers often heal slowly due to risk factors such as poor nutrition or pressure continually being applied
- Infection may spread locally and further, leading to osteomyelitis and sepsis
- Pressure ulcers are a marker for underlying comorbidities and are associated with an increased risk of death
