Pressure Ulcer Staging and Management

The treatment of pressure ulcers has progressed due to technical advances from manufacturers of wound care products and associations dedicated to the exchange of ideas and clinical experience. As with other chronic wounds, the focus of treatment has shifted from consideration of the wound in isolation, to a broader approach that includes examining and treating the underlying etiology, addressing specific wound requirements with specialist dressings, and treatment of the patient as a whole; for example, with systemic factors such as nutrients and antibiotics.

It is now recognized that pressure ulcers will not heal without assessment and removal of the source of pressure. As simple as this may sound, the treatment of “bed sores” or decubitus ulcers had been seriously impeded by insufficient attention to turning schedules or the application of pressure reduction or relief devices. The development of risk assessment tools has helped establish the many factors that must be addressed to prevent or heal pressure ulcers. Treatment regimes now include management of pressure, mobility/sensation, incontinence, and nutrition, and caregivers now implement treatments that cover all aspects of the patients’ needs and wound treatment requirements. Many niche products have been developed to support care of patients prone to pressure ulcers. In addition to pressure relief products, there are sensitivity testing products, probes for diagnosing un-viable skin, posture improving rehabilitation products, products to monitor and indicate too much pressure for too long, and compliance monitors for nursing staff and patients.

Recognition of immobility as a risk factor has led to the establishment of standardized turning schedules for bed-bound patients and repositioning schedules for chair-bound individuals, such as paraplegics confined to wheelchairs. Repositioning schedules and good wound care will continue to help many to heal; however, those patients with the greatest number of risk factors will require pressure-reduction or pressure relief devices to decrease pressure and re-establish sufficient blood flow to the wound.
Manufacturers responded quickly to market demand with a proliferation of pressure reducing products including massive air-fluidized beds, low air-loss beds and mattress covers, and a plethora of foam and gel products. Faced with a large number of choices, clinicians have understandably been overwhelmed by the sheer number of alternative devices and price points. This market is defined by generic products that compete on a cost competitive platform with suppliers offering a full line of products that will suit an individual customer’s particular treatment bias.

After relieving the pressure, proper maintenance of the wound environment becomes imperative for proper healing. Clinicians who used early transparent film dressings readily observed that wounds with a warm, moist surface healed more rapidly and with fewer complications than those allowed to dry out under gauze pads. Exuding wounds, however, required constant maintenance to remove excess fluid that built up under transparent dressings with frequent dressing changes or aspiration of fluid through the dressing.

Hydrocolloid dressings, introduced in the 1980s, absorbed fluid and sustained a moist wound environment for an extended period of time. Hydrocolloids rapidly replaced transparent dressings in exuding wounds, and both physicians and nurses soon became proponents of the “moist wound healing” philosophy. Regardless of their initial claims, all subsequent advanced wound care dressings have been more or less ranked by their fluid-handling ability in practice. For example, alginate dressings were launched with interesting claims suggesting that some ion exchange properties affected wound healing; however, alginates are now generally considered useful when exudates exceeds that easily managed by hydrocolloids.

The next factor considered by the clinician is the need to fill the wound void including the crater, undermining, and sinus tracts. A foam dressing may be used if there is a significant crater to fill and the wound is exuding. Hydrocolloid pastes and powders are used to fill dead space and increase absorptive capacity.

Nutritional support for pressure ulcer patients has been recognized as contributing to faster wound healing. Proper nutrition is necessary to provide sufficient calories to support the nutritional needs of the wound. Various nutritionally based claims have been made for topical supplements, such as zinc in bandages, but the evidence supporting such claims remains inconclusive. However, anabolic steroids, growth factors, gene therapy and tissue-engineered constructs have been suggested for use in patients to encourage the production of granulation tissue and increase the padding that is provided by muscle mass.

Manufacturers promoting their products need to respond to the reality of pressure ulcer care and provide comparative performance data and supporting clinical evidence. Their products should fall within the context of the overall treatment protocols and include pressure reduction, moist wound care, and nutritional support in order to gain credibility with the sophisticated buyer.

Staging of Pressure Ulcers

  • Stage I ulcers are indicated by damaged friable surface skin with considerable hidden cell death caused by continuous pressure damage usually from immobilization in a single position. Identification of signs of pain and early indications of visible damage is a significant event in that it alerts caregivers of the need for interventions to prevent more serious damage. 
  • Stage II ulcers present as partial thickness wounds, which may heal with early intervention by regeneration under advanced wound care techniques. 
  • Stage III ulcers are usually full-thickness pressure sores. These are often difficult to classify due to the presence of eschar that obscures visualization of the wound bed. The presence of eschar does indicate a full thickness wound but the eschar must be removed (debrided) before classification can be established. 

    Early Stage III or Stage IV pressure ulcers may superficially resemble Stage I ulcers. A wound initially classified as Stage I may, therefore subsequently appear to progress to higher stages as the already damaged deeper tissues slough off or as auto-debridement occurs with moist wound healing therapy. 

  • Stage IV  ulcers are characterized by full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining of healthy surrounding skin and sinus tracts may also be associated with Stage IV pressure ulcers.

The success of the four-stage system of pressure ulcer classification has led to attempts to utilize it for other wound types, with varying degrees of success. The four-stage system was developed for the initial assessment of the wound by determining the depth of injury and tissues involved. As full thickness wounds heal by granulation and scar formation it is inappropriate to use the system to describe the process of healing. Stage IV wounds do not become Stage III wounds during the course of healing. Tissues destroyed during the wounding process are not regenerated in full thickness wounds.

There are approximately 4.5 million pressure ulcers in the world that require treatment every year. Many chronic wounds around the world are treated sub-optimally with general wound care products designed to cover and absorb some exudates. The optimal treatment for these wounds is to receive advanced wound management products and appropriate care to address the underlying defect that has caused the chronic wound; in the case of pressure ulcers a number of advanced devices exist to reduce pressure for patients.Pressure ulcers occur most frequently over bony prominences where the padding effect provided by adipose tissue and muscle is least present. Pressure ulcers may also occur under casts, orthopedic devices and under compression bandages and stockings. The majority of pressure sores occur in the following regions:- lower spine (40%), feet (21%), trochanters 20%), scapula (5%), with upper spine, elbows, ribs, head, knees, and lower limbs making up most of the remainder.

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From "Worldwide Wound Management, 2008-2017: Established and Emerging Products, Technologies and Markets in the U.S., Europe, Japan and Rest of World", (Report #S247, published by MedMarket Diligence, LLC.)

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