Ulcers - pressure sores
Description
- Localised injury to skin/underlying tissue from unrelieved pressure +/- shear, usually over a bony prominence
- Staged I-IV plus unstageable and deep tissue pressure injury (DTPI) per NPUAP/EPUAP/PPPIA classification
Epidemiology
- Hospital-acquired prevalence several percent, higher in ICU, immobile, and residential aged care
- Sacrum, heels, ischial tuberosities, greater trochanter commonest sites
Aetiopathogenesis
- Sustained pressure -> capillary occlusion -> ischaemia -> tissue necrosis
- Shear and friction compound direct pressure damage
- Risk factors - immobility, malnutrition, moisture (incontinence), reduced sensation (neuropathy, sedation, spinal injury), reduced perfusion (PAD, hypotension, vasopressors), advanced age (skin fragility)
Diagnosis
Risk assessment
- Validated tool - Waterlow or Braden scale on admission and with clinical change
Staging
| Stage | Findings |
|---|---|
| I | Non-blanchable erythema, intact skin |
| II | Partial thickness loss - shallow open ulcer/blister |
| III | Full thickness - subcutaneous fat visible, no bone/tendon/muscle exposed |
| IV | Full thickness - bone/tendon/muscle exposed |
| Unstageable | Base obscured by slough/eschar |
| DTPI | Persistent non-blanchable deep red/purple/maroon discolouration, intact or non-intact skin |
- Assess for infection - increasing pain, malodour, purulent exudate, surrounding cellulitis, systemic signs
- Probe-to-bone test / imaging (MRI) if osteomyelitis suspected
Management
Prevention (highest yield)
- Regular repositioning (2-4 hourly or per risk), pressure-redistributing mattress/cushion
- Skin inspection at every position change in high-risk patients
- Manage moisture (continence care), optimise nutrition (protein, adequate calories, consider dietitian/supplements)
- Minimise shear - proper transfer technique, avoid head-of-bed >30 degrees unless clinically required
Treatment by stage
- I-II - offload, protective dressing, moist wound environment
- III-IV - debridement of necrotic tissue (surgical/enzymatic), advanced dressings per exudate, specialist wound/plastics referral for complex/non-healing
- Treat infection if present - swab/tissue culture if clinical infection (not routine surface swabs), antibiotics per culture, surgical debridement for osteomyelitis/deep infection
- Nutrition optimisation critical to healing - protein-energy supplementation
Documentation
- Photograph, measure, stage at baseline and each review - medicolegal and quality-of-care importance
Associations
- Immobility, spinal cord injury, sedation
- Malnutrition, low albumin (marker of severity, not diagnostic of malnutrition alone)
- Incontinence
- Peripheral vascular disease, diabetes
- Advanced dementia/end-of-life - pressure injury risk rises sharply, sometimes despite optimal care (Kennedy terminal ulcer - rapid-onset pressure injury near end of life)
Natural history & complications
- Stage I-II usually heal with offloading + basic care
- Stage III-IV - prolonged healing (weeks-months), risk of osteomyelitis, sepsis
- Independent marker of poor prognosis/mortality in frail and end-of-life patients
- Pressure injuries are a key hospital-acquired complication indicator - quality/safety marker
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