History and exam
Key diagnostic factors
common
presence of risk factors
Key risk factors include immobility, age >70 years, recent surgery or intensive care stay, and malnutrition.
use of non-pressure-relieving support surface
A patient of any age with a wound or area of discoloured skin who has been lying totally immobile for an extended period on a surface not specifically designed to reduce the possibility of pressure damage.
Conventional mattresses, operating tables, trolleys, and wheelchair support surfaces do not provide adequate protection against pressure damage for patients who are unable to reposition themselves.
localised skin changes on areas subjected to pressure
Non-blanching erythema or purple or maroon localised area of discoloured intact skin, which may be painful, firm, mushy, boggy, or warmer or cooler than adjacent tissue.
This indicates early stage of tissue damage or probable wound formation.
shallow open wound or tissue loss on areas subjected to pressure
A blister or a shiny or dry shallow ulcer involving partial loss of dermis without slough indicates a stage 2 pressure ulcer.
full-thickness wound on areas subjected to pressure with or without undermining (tunnelling)
Full-thickness wound possibly containing some slough with no bone tendon or muscle involvement/exposure indicates a stage 3 pressure ulcer.
full-thickness wound with involvement of major tissues on areas subjected to pressure with or without undermining (tunnelling)
Full-thickness tissue loss with exposed bone, tendon, or muscle possibly containing slough or eschar on some parts of the wound bed indicates a stage 4 pressure ulcer.
When there is exposed bone, osteomyelitis should be considered.[55]
localised tenderness and warmth around area of wound
Suggests infection.
increased exudate and/or foul odour
Indicators of infection include the following: development of odour and excess exudate from a previously clean wound, change in the appearance of the wound bed, or a sudden deterioration in the condition of the wound or the patient.
Risk factors
strong
immobility
All patients who have impaired mobility are at risk of developing pressure ulcers. Immobility may be permanent, such as from a stroke, or transitory, such as from sedative or restraint use.
sensory impairment
Neurological impairment resulting in loss of sensation may prevent normal self-repositioning in response to noxious stimuli.
older age
surgery
Surgery, with its accompanying immobility and impaired sensation, places patients at considerable risk of pressure ulcer development.
One systematic review and meta-analysis found that, across all hospital departments, the highest incidence of pressure ulcer occurred among inpatients on orthopaedic surgery wards (18.5%; 95% CI: 11.5-25.0).[3] The risk may be particularly great with orthopaedic surgery following a hip fracture.[18]
intensive care stay
Patients in intensive care units are at high risk of developing pressure ulcers due to immobility, sedation, and cardiovascular instability. Risk increased as a function of time such that, in one study, the cumulative risk was 50% at 20 days.[19]
malnourishment
Pressure ulcers are significantly more common in patients who are malnourished.[5]
A mini-nutritional assessment conducted in 484 multimorbid older patients revealed that 39.5% of patients with ulcers were malnourished and 2.5% were well nourished. Of patients without pressure ulcers, 16.6% were malnourished and 23.6% were well nourished.[20] How malnutrition interacts with pressure to cause skin damage is uncertain but may include alterations in skin resistance to pressure damage or impaired healing of early pressure-induced damage.
Malnutrition also relates to body weight. Lower body-mass index is clearly associated with increased risk of pressure ulcer development; the risk at a very high body-mass is less certain.[21]
history of previous pressure ulcers
Stage 3 and 4 pressure ulcers heal through a process involving wound contraction and scar tissue formation. The resulting tissue is not normal skin and is particularly prone to break down again.
environmental factors
The likelihood of developing pressure damage is greatly influenced by the nature of the surface on which the patient has been sitting or lying.
Conventional mattresses, operating tables, trolleys, and wheelchair support surfaces do not provide adequate protection against pressure damage for patients who are unable to reposition themselves regularly for whatever reason. An immobile patient who has been nursed on an inappropriate mattress is greatly at risk of developing pressure damage, and therefore consideration of these factors can add support to a diagnosis of pressure-induced injury.
weak
faecal or urinary incontinence
Skin wetness is frequently cited as a contributory factor to skin damage and moisture-associated dermatitis. How moisture may lead to deep tissue damage is less certain and some studies suggest that urinary incontinence is only an indicator for other risk factors or a measure of the need for care without any causal relation to pressure sores.[22] The possible relationship between microclimate at the skin surface and deep tissue injury is only beginning to be recognised.[12]
Faecal incontinence may be a more significant risk factor, perhaps as a result of toxic substances present in faeces.[23]
diabetes
peripheral vascular disease
People with peripheral vascular disease have poor blood flow to the legs and are at particular risk for pressure ulcers of the heel.
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