Pressure Injuries and Ulcerations
Published: 17 August 2016
Published: 17 August 2016
Pressure injuries may never heal if the patient is failing to consume adequate food and fluids to maintain body functions and assist tissue growth.
An additional complication could be underlying involvement of the bone (known as osteomyelitis) in deep pressure injuries.
If osteomyelitis is not managed appropriately by a qualified physician, it may result in serious sequelae and the possibility of the wound never healing.
(It is a given that when managing pressure injury risk and actual damage, the pressure is relieved, and attention is given to nutritional requirements.)
There are now six classifications of pressure injury.
Intact skin with non-blanchable redness of a localised area, usually over a boney prominence.
A stage one pressure injury is an intact area of damage, so protection of the tissue and providing an environment for recovery is the aim.
Adhesive foams can be employed if moisturising the area on each shift is not possible. Examples of adhesive foam include Mepilex Border™ and Allevyn Life™.
Partial thickness loss of dermis presenting as a shallow, open- wound with a red/pink wound bed, without slough or bruising. May also present as an intact or ruptured serum-filled blister. Shiny or dry.
Stage two pressure injuries are relatively clean, superficial, partial-thickness injuries. Once again, protection is important, however due to the break in the integument, the chosen dressing must also have some absorbent capabilities.
Adhesive foams are generally appropriate here, unless the wound is located very close to the anus, in which case a thick barrier cream is often used. Conveen Critic Barrier Cream™ is one appropriate example.
Full thickness tissue loss, subcutaneous fat may be visible, slough may be present.
Stage three injuries involve damage through to the subcutaneous tissue, with the presence of slough and soft, tenacious necrotic tissue, which will require debridement.
Debridement can be as previously mentioned: managed by a surgeon, a skilled clinician, or using dressings to aid autolytic processes. Dressings that aid this autolysis include: Flaminal Hydro or Forte™, Prontosan Gel™, Mesalt™ and Iodosorb™ powder or ointment.
Whilst the autolytic process is taking place, the wound exudate will be higher in volume, so super absorbent pads will be required as the secondary dressing, for example Zetuvit Plus™.
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present.
Stage Four implies that the area of damage extends down through muscle and bone may be exposed or palpable. These injuries are generally necrotic and malodourous. Managing odour becomes the priority.
Metronidazole Gel™ will typically reduce odour in a few days. HydroClean Plus™ is a preloaded pack of PHMB, that slowly drips into the wound, aiding autolytic debridement, and can safely be used with Metronidazole Gel™.
If the patient is in otherwise good health, then surgery and Topical Negative Pressure devices would be used.
Unstageable pressure injury (depth unknown): full thickness tissue loss, base is covered by slough and/or eschar (yellow / brown/ black) in the injury bed.
The aim here is to remove the necrotic tissue until viable tissue is reached and the wound can begin to heal from the base up.
Debriding products previously mentioned can be used on this category.
Suspected deep tissue injury (depth unknown): purple/maroon localised area of discoloration of intact skin or blood-filled blister. May develop thin blister or eschar over dark wound bed.
The aim here is to preserve the tissue intact for as long as possible and await what the body can do if the pressure is removed. Most clinicians take a -watch and wait approach. Dressings that seal the area off can sometimes create more moisture and heat making the tissue more vulnerable to further damage.
Although there are many types of leg ulcers, the most common are venous, followed by arterial, and then mixed venous arterial.
The classic signs and symptoms of each of these ulcer types can be found in the Australian and New Zealand Clinical Practice Guideline for Venous ulcer prevention and management.
Ulceration of lower legs is often complex as the diagnosis may not have been made.
Venous ulcers can heal with compression therapy, however conversely some arterial ulcers may deteriorate if compression is used.
Therefore having a knowledge of the characteristics of venous and arterial ulcers is imperative to ensure appropriate decision-making regarding management of these wounds.
Venous ulcers are located in the lower third of the lower-leg and generally are superficial and weeping.
The priority of care is managing the oedema and encouraging the epithelium to grow across the superficial break.
Zinc paste bandages and compression bandages are the mainstay of treatment to achieve these goals. The zinc paste bandages may include products like Viscopaste™ or Varicex™.
If the wound has been present for a considerable length of time, then some bacterial involvement is likely, and so an antimicrobial is suggested such as Iodosorb Powder™ or Sorbact compress™. This could then be combined with a super absorbent pad such as Zetuvit Plus™.
Compression therapy selection is complex and must be tailored to the patient. A safe and effective system from which to start, however, is the use of straight, elasticated tubular bandages, for example Tubigrip™ or Tubular Form™.
These must be applied from toes to knee after selecting the appropriate size according to the manufacturers guide. Commence with one layer, if tolerated then add another second layer but extending to only 2/3 of the lower leg and finally if tolerance is maintained then add another 1/3. This is known as 3 layers straight elasticated tubular bandage-allowing removal of the upper layers for sleeping then re-apply next morning.
When it comes to managing arterial ulceration, a vascular surgeon is best to consult as ideally some surgery can be performed to restore perfusion to the limb. It then becomes the attending clinician’s role to prevent infection.
Generally the rule is: if the tissue is dry and ischaemic, then keep it dry. So Betadine™ lotion is used to achieve this and keep the eschar dry.
If the tissue in the arterial wound is offensive, infected or malodourous, then a silver or cadexomer iodine may be used, such as Aquacel Ag™ or Iodosorb™ ointment/powder.
Identifying the wound type, setting a clear aim for management, and then the selection of product or device, remains the mainstay of wound management principles. There are of course many other factors to be considered when addressing patients with wounds, and reviewing a wound in isolation of these other factors may lead to poor healing progress.
Nutrition, skin care, patient motivation, financial circumstances, environment and psychological state, all play a part in wound healing. It is best to have structure in assessment in order to decipher the wound aetiology, look at factors influencing healing, address these as able, and then select a product based on the aim.
Keep your formulary up to date with what is considered best practice and review the wound regularly to ensure progress.
For a full guide to wound care and wound healing, visit: https://www.ausmed.com.au/guides/wound-care.
Jan Rice is a Registered Nurse with many years of experience in surgical nursing. Jan is a member of the Venous Leg Ulcer Guideline Implementation sub-committee and the Pressure Injury Guidelines Development sub-committee. Jan obtained a Masters in Wound Care in 2009 and runs a wound clinic in a large Metropolitan General Practice — Ashwood Medical. Through her own business, Jan has been acting as a consultant to over 80 aged care facilities and a resource for Divisions of General Practice and surgeons within Victoria. Jan is an author of a book chapter on wound healing and has been a volunteer with Interplast since 1983. In 2006, she was awarded Fellowship to the Australian Wound Management Association. See Educator Profile