The Stages of a Pressure Ulcer and Treatment:
By: Kristen Ianuzzi and Danae Abel-Templin
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Description and Illustration
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Treatment and Photograph
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Stage 1:
Sores are not yet open wounds, the skin may be painful but it has no breaks or tears. The skin appears reddened but doesn’t blanche. The stage 1 sore can feel firmer or softer than the area around it.
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● Keep pressure off of the sore using foam or similar pressure redistribution surfaces
● Minimize seating time
● Modify sitting-time schedules and posture
● Protect the sore from any future tissue damage
● Gently wash the wound with mild soap and water and pat dry
● Evaluate the diet for proper nutrients ● Review mattresses, wheelchair cushions, pressure releases, and transfers for a possible cause
● Potentially use a protective dressing like Tegaderm
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Stage 2: The skin breaks open, wears away, or forms an ulcer which is usually tender or painful. The sore expands into deeper layers of the skin. At this stage, some skin may be damaged beyond repair or die.
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● Follow the same steps as above but use a saltwater solution for cleaning as the skin is open. ● Check for wound healing with each dressing change
● Check for signs of infection
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Stage 3: The sore gets worse and extends into the tissue underneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone yet.
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● Follow the previous stages but be mindful of the fact that these wounds may need additional care with special cleaning and debriding agents. Antibiotics may be required.
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Stage 4: The sore is very deep, extending into muscle and bone, causing excessive damage and sometimes extending to tendons and joints.
**In stage 3 and 4 there may be no pain due to significant tissue damage. Serious complications can occur if sore progresses**
 Illustrations Retrieved from:
http://www.npuap.org/
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● The healing of these ulcers may take more than 6 months and sometimes never heal
● Stage 4 pressure ulcers often require skin grafting and surgeries for debridement.
● Special beds are most necessary at this stage
 Images Retrieved From: http://www.msktc.org/sci/factsheets/skincare/Recognizing-and-Treating-Pressure-Sores
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The Multidisciplinary Team (MDT) typically includes a combination of the following processionals:
● Physician
● Tissue Viability Nurse: This individual will specialize in wound care and prevention
● Social Worker: Works with family and doctor to make informed decisions and helps to identify community resources
● Dermatologist
● Physiotherapist: Will provide manual therapy, dressings, possible electrophysical agents, functional mobility, and ongoing reassessment of wound.
● Occupational Therapist: Will provide manual therapy and positioning, educate caregivers
● Dietitian:Provides nutrition and often calorie supplements to augment the diet in order to provide the patient with adequate nutrition for skin integrity. Malnourished patients are at high risk for developing pressure ulcers (Jaul, 2010).
Occupation-Based Treatment:
● In a cross-sectional survey, OTs expressed that they were involved in decision making concerning dressing or topical agents, determination of the causation of the wound, involvement after tissue healing, and involvement in prevention of a new ulcer
○ Determining causation of presenting wound: this process is not standardized. The most common assessment that was reported was a seating evaluation to determine the cause of the wound
○ Involvement after tissue healing: this includes progressive range of motion, initial remobilization (first sitting), and instruction in pressure relief maneuvers/techniques, and instruction on safe transfers
○ Involvement in prevention of a new ulcer: this can involve assessing new equipment to address seating needs, assessment of transfer safety, assessment of bathroom equipment, educating the patient on skin inspection
○ Almost all OTs reported that doing a seating evaluation was part of their prevention strategy
● An OT could use the Braden-Scale to assess a patient’s risk for pressure ulcers. Using the scores from this scale, the occupational therapist could focus treatment on specific areas of the scale like sensory perception, activity, and nutrition.
○ Sensory Perception: the OT could regularly inspect the skin and instruct the patient on proper bed positioning and educate the family of the patient as well.
○ Moisture: OT can determine if a bedside commode is appropriate to reduce accidents and work on transfers from bedside to commode.
○ Activity: OT can work on deficits in motility which contribute to pressure sores and train the patient in rolling, sitting to supine, etc… Education is an important piece of this because even minor changes in positioning have dramatic effects.
○ Nutrition: OT can work on self-feeding because deficits arise from decreased range of motion, muscle strength, and fatigue. The OT will coordinate care with the other members of the team and caregivers to encourage food choices.
○ Friction: The OT will instruct on movements to decrease friction and the use of tools which may increase or decrease friction. For example a sliding board may increase shearing.
○ (Ryan, 2006).
Beds for Pressure Sores:
There are a variety of bedding options for preventing pressure sores. They range from low-tech surfaces, like air filled mattresses and overlays, gel filled mattresses, and sheepskins, to high-tech surfaces with dynamic support relief like lateral rotation mattresses and alternating pressure mattresses. As the stages of the ulcer progress, there is an increased need for specialized bedding.
● A study by Manzano and his colleagues (2013) found that in a sample of 221 students in the medical surgery intensive care unit of a university hospital on mechanical ventilation, alternative pressure air mattresses were more effective in preventing pressure ulcers than alternating pressure air overlays.
● A Belgian study by Demarre and colleagues (2013) found that in a study of hospitalized patients, fewer patient developed ulcers laying on a multistage alternating low-pressure air mattress (ALPAM) than patients laying on a one-stage ALPAM or alternating pressure air mattress (APAM) overlay.
The Dolphin Bed:
Since the 1960s, the Navy has trained dolphins for important force protection and rescue missions. When attempting to transport the dolphins for long distances outside of the water, the dolphins were subjected to harsh vertical shear forces of gravity because their skin and organs are so sensitive to pressure. The dolphin FIS system was created to solve this problem. The dolphin beds simulate a fluid environment that attempts to maintain normal blood flow and optimize tissue oxygenation. People began to notice that a bed like this could also be beneficial for humans in a hospital setting, as humans, too, have delicate skin that can be easily injured..
● Institutions incorporating and/or assessing dolphin beds: Veterans Health Administration, Cleveland Clinic, University Hospitals Case Medical Center, University of Nebraska Medical Center, Baylor Health Care System, Johns Hopkins Hospital, University of Alabama at Birmingham Hospital, Indiana University Hospital
● A Study conducted by VA La Jolla Medical Center and Division of Plastic Surgery, UC San Diego. 10 volunteers had their tissue perfusion measured in various positions on a standard or dolphin mat. Volunteers that used the dolphin beds demonstrated higher retention rates from baseline perfusion compared to those who used standard beds by 71% (The Advisory Board Company, 2009).
● Memphis VA Medical Center is a 225-bed hospital with a 60-bed SCI center. They purchased 44 dolphin mats to use on two of their SCI units with the goal of reducing pressure ulcer development or progression as well as to reduce rental costs associated with air-fluidized mattresses. Found that with the dolphin beds they reduced pressure ulcer incidence from 11% to 0% and reduced rental costs (The Advisory Board Company, 2009).
Cost-Effectiveness and Alternatives:
● Dolphin FIS Bed = $18,000
● Med-Aire Plus Alternating Pressure Low Air Loss Mattress System with Raised Edge = $1,249.00
● Hill-Rom 300 Wound Surface Alternating Pressure Mattress System with Low Air Loss= $2,850
● Studies have shown that bedding options, whether high-tech or low-tech are more preventative than hospital mattresses for pressure ulcers. Medical Sheepskin is significantly more cost-effective than an alternating pressure mattress, but also is not as effective. Some medical sheepskins cost as little as $200. (McInnes)
References:
Demarré, L., Verhaeghe, S., Van Hecke, A., Grypdonck, M., Clays, E., Vanderwee, K., & Beeckman, D. (2013). The Effectiveness of Three Types of Alternating Pressure Air Mattresses in the Prevention of Pressure Ulcers in Belgian Hospitals. Research In Nursing & Health, 36(5), 439-452. doi:10.1002/nur.21557
Jaul, E. (2010). Assessment and management of pressure ulcers in the elderly. Drugs & Aging, 27(4), 311-25.
Guihan, M., Hastings, J. & Garber, S. (2009). Therapists’ role in pressure ulcer management in persons with spinal cord injury. The Journal of Spinal Cord Medicine, 32(5), 560-567.
Hartmann, P. (n.d.) Phase-specific wound management of decubitus ulcer. Retrieved from: http://en.hartmann.info/images/decubitus_ulcer_GB_09.pdf
Joerns. Dolfin fluid immersion simulation. Retrieved from: http://www.joerns.com/wound-solutions/dolphin-fluid-immersion-simulation
Lyder, C. (2011). The benefits of a multidisciplinary approach to the prevention and treatment of pressure ulcers. Infection Control Today. Retrieved from: http://www.infectioncontroltoday.com/news/2011/08/the-benefits-of-a-multi-disciplinary-approach-to-the-prevention-and-treatment-of-pressure-ulcers.aspx
Manzano, F., Pérez, A., Colmenero, M., Aguilar, M., Sánchez-Cantalejo, E., Reche, A., & … Fernández-Mondejar, E. (2013). Comparison of alternating pressure mattresses and overlays for prevention of pressure ulcers in ventilated intensive care patients: a quasi-experimental study. Journal Of Advanced Nursing, 69(9), 2099-2106. doi:10.1111/jan.12077
McInnes E, Jammali-Blasi A , Bell-Syer SEM, Dumville JC, Cullum N. Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews: Version 2011, Issue 4. CD001735.
Nursing Executive Center. (n.d) Best practices for preventing ulcers and patient falls. Retrieved from: http://www.dolphinfis.com/_assets/pdf/Dolphin%20Advisory%20Panel%20Report.pdf
Ryan, J. (2006). Teamwork keeps the pressure off: the role of the occupational therapist in the prevention of pressure ulcers. Home Healthcare Nurse, 24(2), 97-102.