Physical examination, medical and nursing history, and patient and caregiver observation are the basis of diagnosis. Special attention must be paid to any physical or mental impairment such as incontinence or confusion that could complicate a patient's recovery. Staging is done based on the wound's characteristics and depth of soft tissue damage. Correct staging can only be done after all necrotic (dead) tissue has been removed, allowing for complete inspection of the wound bed (area). According to the National Pressure Ulcer Advisory Panel, once a particular stage (I, II, III, or IV) has been assigned to a pressure ulcer, it will always remain at that stage. Although pressure ulcers will heal to progressively more shallow depths, they do not replace the lost muscle, fat, or dermis. Instead, the ulcer is filled in with scar tissue. Therefore, when a Stage IV ulcer has healed, it should be classified as a healed Stage IV ulcer, not a Stage 0 ulcer.
The desired outcomes of pressure ulcer treatment are to protect the remaining healthy cells, heal the ulcer completely, and prevent the formation of other pressure ulcers. If addressed promptly, surface pressure ulcers can be prevented from developing into more serious wounds.
Pressure ulcer management contains four basic components:
Debridement. This is a procedure that involves the removal of dead tissue or other debris from the wound. Debridement can be done by a sharp method, where the tissue is actually cut out with a scalpel or other sharp instrument; and is usually performed by a physician, physician's assistant, or an advanced practice nurse. Another method is mechanical debridement, which utilizes wet-to-dry dressings, wound irrigation, and dextranomers (beads placed into the wound bed to absorb drainage). Enzymatic debridement utilizes certain topical debriding agents to help remove the dead tissue. Autolytic debridement uses synthetic dressings that help the involved tissue self-digest from enzymes that are contained in wound fluids. This last-mentioned method should not be used for infected pressure ulcers.
Cleansing. Normal saline is the recommended solution for cleansing wounds because it does not harm the wound bed, and it adequately cleanses the majority of wounds. Such solutions as hydrogen peroxide, povidone iodine, iodophor, and acetic acid are cytotoxic (toxic to cells), and should not be used. There are several commercially prepared wound cleansers containing surfactants (surface-active substances) and other ingredients, but these may also have some toxic effects on the cells. In order to minimize wound damage during cleansing, appropriate irrigation methods should be used. Too little pressure, such as that produced with a bulb syringe, yields poor results; while too much pressure will cause damage to healthy tissue. Irrigating the ulcer using a 35-ml syringe with a 19-gauge angio-catheter will usually provide enough pressure to get rid of eschar (scabs), bacteria, and other debris. In addition, the use of daily whirlpool treatments may help facilitate the removal of necrotic tissue.
Infection management. Because of the various factors that may affect a patient's resistance to infection, the patient should be closely monitored for any signs of infection in the wound so that antibiotics can be initiated promptly. These signs include a sudden deterioration of the ulcer; changes in the color or texture of the granulation (new capillaries formed on the surface of a wound in healing) tissue; or alterations in the amount or appearance of the wound drainage. In addition, any increase in redness, edema, or tenderness of the ulcerated area should be reported to the physician.
Dressings. When selecting a dressing for a pressure ulcer, the most important factor is the ability of the dressing to keep the wound bed moist and the surrounding healthy, intact skin dry. There are numerous types of dressings available; and selecting one should be a determination based on the preference of the physician and nurse, the time available to perform wound care, and the specific conditions of each wound.
Other adjunctive treatments that promote healing include electrical stimulation, ultrasound, hyperbaric (high pressure) oxygen, and laser irradiation. If there is extensive tissue necrosis, or if there are signs of infection, the physician may order topical and/or systemic antibiotic treatment. Very deep ulcers that do not respond to treatment may require skin grafts or plastic surgery.
Many patients are interested in complementary or alternative treatments, and several have been suggested in the treatment of pressure ulcers. Zinc and vitamins A, C, E, and B complex help skin repair injuries and stay healthy, but large doses of vitamins or minerals should not be used without consulting a physician. Various herbal remedies, including a tea tree oil rinse and an herbal tea made from the calendula plant, may act as antiseptic agents. Again, the physician or health care profesional should be consulted when considering any of these treatments.
Deanna M. Swartout-Corbeil R.N., The Gale Group Inc., Gale, Detroit,