Pressure Ulcers

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Treatment
The treatment of pressure ulcers begins with a comprehensive assessment of both the patient and the wound.
Wounds should be evaluated for stage, size, sinus tracts, necrotic tissue, exudate, and the presence of granulation. This may be facilitated by using the staging systems described above.
Attention to precipitating factors is central to the treatment of all pressure ulcers. Preventive measures that are already in place should be reviewed and their intensity increased. This is particularly true for stage 1 ulcers, which may be a warning that more serious lesions are to follow.
Stage 2 pressure ulcers usually require an occlusive or semipermeable dressing that will maintain a moist wound environment. Wet-to-dry dressings are avoided since these wounds generally require little debride-ment.


Nutritional status
Several small clinical trials have suggested that an increase in dietary protein intake promotes the healing of pressure ulcers. Protein intake of 1.0 to 1.2 g/kg/day is generally recommended for all patients with pressure
ulcers.
Tissue pressure
Patients should be positioned to minimize or avoid all pressure on the wound. In addition, specialized beds may assist with pressure sore healing in some patients. A consensus on the use of these specialized beds
does not exist, in part due to their high cost. Most pressure ulcers can be successfully managed without the use of a specialized bed.
A static support surface such as a foam, air, or water overlay may be used if the patient can assume a variety of positions without bearing weight on the ulcer. A dynamic support surface should be considered when the patient cannot assume such positions or if the pressure ulcer does not show evidence of healing. A low air-loss or air-fluidized bed may be necessary for patients who have large ulcers at multiple sites on the body that make positioning difficult.
Wound debridement
Necrotic tissue promotes bacterial growth and impairs wound healing. Thus, wound debridement is an important element of pressure ulcer treatment. Four approaches to debridement are available; they are often used in combination: Mechanical debride-ment includes the use of wet-to-dry dressings, hydrotherapy, wound irrigation, and scrubbing the wound with gauze. These approaches are best for wounds that contain thick exudate, slough, or loose necrotic tissue. Wet-to-dry dressings will remove both nonviable and viable tissues; caution is required in their use. Moistening the dressing before removal should be avoided since it will limit the debriding effect. Sharp debridement involves the use of a scalpel or scissors. It may be performed in the operating room or at the bedside. This is the most rapid form of debridement; it is indicated when there is evidence of cellulitis or sepsis. Sharp debridement is also used to remove thick eschar and when there is extensive necrotic tissue. The exception is patients with heel ulcers covered by a thick, dry eschar, in whom removal is often not recommended. Enzymatic debridement using the topical application of agents such as collagenase, papain, fibrinolysin, and deoxyribonuclease is effective in promoting the growth of granulation tissue. These agents are particularly useful in long-term care settings and in patients who may not tolerate surgery. Crosshatching of the wound with a scalpel is required prior to the application of enzymatic agents on eschars. Autolytic debridement uses an occlusive dressing to cover a wound so that necrotic tissue is digested by enzymes normally present in wound tissue. This often works best on wounds with minimal exudate. It should not be used in the presence of infection.
Debridement should stop once necrotic tissue has been removed and granulation tissue is present.

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