**7. Pressure ulcer treatment**

The treatment of pressure ulcers is based on the physiology of wound healing. Wound healing is a complex process that changes with the health status of the individual [17]. A health care provider needs to have a basic knowledge of the phases of wound healing including; hemo‐ stasis, inflammation, proliferation and maturation. Once a provider understands wound healing, one has a significant piece of the knowledge necessary to develop a pressure ulcer treatment plan [18].

### **7.1. Phases of wound healing**

The first phase of wound healing is hemostasis. Briefly, in this phase, damaged blood vessels are sealed when platelets form a stable clot to seal the blood vessel. The platelets also stimulate the clotting cascade through the production of thrombin that initiates the production of fibrin. The fibrin mesh ultimately strengthens the platelet aggregate into a hemostatic plug. Hemo‐ stasis occurs within minutes of injury unless the injured individual has underlying clotting disorders [18].

In the second phase of wound healing, the inflammation phase, the erythema, swelling and warmth that occur are often associated with pain. This phase of wound healing usually lasts up to 4 days after injury. During this phase, neutrophils or PMN's (polymorphonucleocytes) and plasma are leaked from the blood vessels into the surrounding tissue. These factors clean debris from the surrounding tissue and provide the first line of defence against infection. Macrophages are also active in the second phase of wound healing acting to destroy bacteria and secreting growth factors which direct the third phase of wound healing.

Chronic wounds, wounds that take longer than 12 weeks to heal, often remain in the inflam‐ matory stage longer than occurs with acute wounds. Cellular and molecular abnormalities within a wound bed prevent progression through the stages of healing [19]. Chronic wounds contain elevated inflammatory cytokines and proteases. Chronic wounds do not respond to growth factors in the same manner in which acute wounds do. Specifically related to pressure ulcers, the volume of exudate is often times increased in chronic wounds. Secondary to infection, the exudate may be more purulent. If protein levels are low, the exudate may appear thinner [19]. Chronic wounds often have inadequate blood supply that also contributes to delayed healing and the formation of unhealthy granulation tissue.

The third phase of wound healing, the proliferation phase, begins approximately 4 days after injury and usually lasts until day 21 postinjury. The activity during this phase is replacement of dermal tissue and possibly subdermal tissue and contraction of the wound. Fibroblasts secrete collagen, which is the framework upon which new dermal regeneration, can occur. Angiogenesis, development of new capillaries, also occurs during this phase of wound healing. Keratinocytes differentiate to form the protective outer layer.

In the final phase of wound healing, maturation, remodeling of the dermal layer occurs to produce greater tensile strength. The cells that are involved in this process are fibroblasts. This process can take up to 2 years to complete [18].

### **7.2. Principles of wound healing**

In addition to knowledge of wound healing, a provider must also be aware of the principles of wound treatment and intervention. For a wound to progress to healing, the wound bed must be well vascularized, free of devitalized tissue, free of infection and moist. Continual evaluation of a wound is necessary as the wound progresses through the stages of wound healing.

### **7.3. Dressings**

instruments are The Braden and Norton scales that have been tested for validity in predicting pressure ulcer development risk [7, 16]. In Britain, the most common scales are the Braden and

These scales will identify specific factors related to assessment categories that place an individual at risk for pressure ulcer development. Once specific factors are identified, a prevention plan to address those factors can be implemented to reduce or eliminate the risk of pressure ulcer development [3, 16]. With the implementation of an evidence‐based pressure ulcer prevention plan, pressure reduction can occur which will preserve the microcirculation and prevent the development of pressure ulcers [17]. A pressure ulcer prevention plan is multifaceted. Factors related to prevention and discussed further in treatment, as these factors are also included in a treatment plan, include; mobility, moisture and continence care, nutrition and hydration, support surfaces, documentation and education. No single intervention has been found that will consistently, reliably and completely reduce pressure ulcer development. Pressure ulcer prevention involves multiple interventions and a multidisciplinary team to

The treatment of pressure ulcers is based on the physiology of wound healing. Wound healing is a complex process that changes with the health status of the individual [17]. A health care provider needs to have a basic knowledge of the phases of wound healing including; hemo‐ stasis, inflammation, proliferation and maturation. Once a provider understands wound healing, one has a significant piece of the knowledge necessary to develop a pressure ulcer

The first phase of wound healing is hemostasis. Briefly, in this phase, damaged blood vessels are sealed when platelets form a stable clot to seal the blood vessel. The platelets also stimulate the clotting cascade through the production of thrombin that initiates the production of fibrin. The fibrin mesh ultimately strengthens the platelet aggregate into a hemostatic plug. Hemo‐ stasis occurs within minutes of injury unless the injured individual has underlying clotting

In the second phase of wound healing, the inflammation phase, the erythema, swelling and warmth that occur are often associated with pain. This phase of wound healing usually lasts up to 4 days after injury. During this phase, neutrophils or PMN's (polymorphonucleocytes) and plasma are leaked from the blood vessels into the surrounding tissue. These factors clean debris from the surrounding tissue and provide the first line of defence against infection. Macrophages are also active in the second phase of wound healing acting to destroy bacteria

Chronic wounds, wounds that take longer than 12 weeks to heal, often remain in the inflam‐ matory stage longer than occurs with acute wounds. Cellular and molecular abnormalities

and secreting growth factors which direct the third phase of wound healing.

the Waterlow. The Jackson Cubbin Scale is specific to European critical care (**Table 4**).

affect the identified factors and reduce the risk of pressure ulcer development.

**7. Pressure ulcer treatment**

332 Wound Healing - New insights into Ancient Challenges

treatment plan [18].

disorders [18].

**7.1. Phases of wound healing**

No one dressing is appropriate for all wounds. There are multiple factors that will affect the dressing selected for a particular wound **Table 5**.

Knowledge of the properties of available wound dressings and an understanding that a treatment plan may need to change as the wound progresses through the stages of healing is vital. Wounds that do not advance through the process of healing in a reasonable or expected time frame must be assessed for issues that have not been previously identified or wound changes that have occurred and the treatment plan re‐evaluated **Table 6**.

The principles in selecting dressings for pressure ulcer treatment include eliminate dead space, control exudate, prevent bacterial overgrowth, ensure proper moisture balance, cost‐efficiency, and manageability for the individual, caregiver and providers.

Several adjuvant therapies/advanced dressings have been used to treat pressure ulcers. These therapies include (a) platelet‐derived growth factor (PDGF) applied to the wound bed, which will stimulate the growth of cells involved in wound healing and granulation tissue formation; (b) negative pressure wound therapy (NPWT), which utilizes subatmospheric pressure applied to a wound via a sealed dressing to promote wound healing, the applied suction removes drainage and increases blood flow to the wound; and (c) hyperbaric oxygen therapy, delivered in multiple modes—total body, body part or mask—exposes the body to 100% oxygen at a higher pressure than normally experienced, this therapy provides oxygen necessary to stimulate wound healing and combats infection by enhancing leukocyte and macrophage activity [20]. PDGR and hyperbaric oxygen, although supported for use, have less support than does NPWT in studies conducted on individuals with pressure ulcers [20].


**Table 5.** Wound description.


**Table 6.** Dressings [17].

There is limited evidence, although moderate strength, indicating support for the use of radiant heat dressings to improve pressure ulcer healing. Radiant heat dressings are noncontact dressings attached to a heating element. These dressings provide warmth to the wound and have been found to increase capillary blood flow to the area and thus increase wound healing. Also with limited yet moderate strength of evidence is the use of electrical stimulation, which provides a direct electrical current through the wound bed using electrodes on the surface of the wound. One hour daily session has been shown to be most effective. Caution has been noted not to use electrical stimulation on individuals with cancer as the treatment could stimulate the cancerous cells. The American College of Physicians specifically notes electrical stimulation in its guidelines [15].

### **7.4. Treatment plan**

delivered in multiple modes—total body, body part or mask—exposes the body to 100% oxygen at a higher pressure than normally experienced, this therapy provides oxygen necessary to stimulate wound healing and combats infection by enhancing leukocyte and macrophage activity [20]. PDGR and hyperbaric oxygen, although supported for use, have less support than does NPWT in studies conducted on individuals with pressure ulcers [20].

Full thickness

Heavily exudating Malodorous Excessively painful Difficult to dress

Slough Granulating Epithelializing

Moist

Infected

Conforms to the wound bed by suction and stimulates wound contraction while removing

Alginate Highly absorbent, useful for wounds with copious exudate. Alginate rope is particularly

Hydrocolloid Useful for dry necrotic wounds, wounds with minimal exudate or clean granulating wounds

There is limited evidence, although moderate strength, indicating support for the use of radiant heat dressings to improve pressure ulcer healing. Radiant heat dressings are noncontact dressings attached to a heating element. These dressings provide warmth to the wound and have been found to increase capillary blood flow to the area and thus increase wound healing. Also with limited yet moderate strength of evidence is the use of electrical stimulation, which provides a direct electrical current through the wound bed using electrodes on the surface of the wound. One hour daily session has been shown to be most effective. Caution has been noted not to use electrical stimulation on individuals with cancer as the treatment could stimulate the cancerous cells. The American College of Physicians specifically notes electrical

Wound depth Partial thickness

Wound description Necrotic

334 Wound Healing - New insights into Ancient Challenges

Wound characteristics Dry

Bacterial description Colonized

Hydrofiber Absorbent dressing used for exudative wounds

Hydrogel Useful for dry, sloughy, necrotic wounds

exudate

useful to pack exudate cavities or tracts

Foam Useful for clean granulating wounds with minimal exudate

Debriding agents Useful for necrotic wounds, often used as an adjunct to surgical debridement

Transparent film Useful for clean, dry wounds with minimal exudate, protect high friction areas

**Table 5.** Wound description.

Negative pressure wound therapy

**Table 6.** Dressings [17].

stimulation in its guidelines [15].

Prior to the development of a comprehensive pressure ulcer treatment plan, consideration should be given to an individual's psychological, behavioral and cognitive status. The individual's goals and prognosis need to be determined as well as the resources an individual has available, both financially and as caregivers.

A multidisciplinary team is needed to develop a comprehensive pressure ulcer prevention and treatment plan, as numerous factors are addressed. The team may include the individual's primary care provider, a wound care specialist, nurses or medical assistants who will provide wound care or education, social workers who will assist the individual and family members with resources and emotional concerns, a physical therapist who will provide assistance with mobility therapy and any other necessary consultants.

Within the plan, the following needs may need to be addressed.

*Debridement* of necrotic tissue within an acute wound may be necessary to be able to com‐ pletely assess the wound. Necrotic tissue may obscure underlying fluid collections that need to be identified. Necrotic tissue also promotes bacterial growth that impairs wound healing and therefore should be debrided [17]. However, debridement is not recommended for stable dry eschar on heel wounds with no edema, erythema or fluctuance. Debridement can be achieved by multiple methods including sharp debridement, mechanical, enzymatic or autolytic debridement. Most sharp debridement can be completed at bedside, yet if more extensive sharp debridement is needed it may need to be performed in an operating room [17].

*Mobilization* of an individual is an important component to a pressure ulcer treatment plan. Since, by definition, a pressure ulcer is caused, in part, by pressure, if an individual begins to mobilize pressure will be relieved individuals who cannot ambulate redistributing pressure on a support surface needs to be investigated.

*Moisture management,* controlling incontinence and excess perspiration by wicking moisture away from the skin, will impact the effect of moisture. Managing moisture will increase the ability of the epidermis to return to its original state after being exposed to pressure. Shear and friction also will not be as detrimental to the skin when moisture is not allowed to be in contact with the skin for prolonged periods of time.

*Nutrition* studies indicated weak evidence that nutritional interventions provide benefits in the prevention or treatment of pressure ulcers [15]. A guideline presented by the American College of Physicians in 2015 cited moderate quality evidence supporting protein supplements in treating pressure ulcers. A Cochrane review in 2014 concluded that there is no evidence to support nutritional interventions, including protein, provide any benefits in preventing or treating pressure ulcers. A study regarding vitamin C supplements concluded that there was no change in wound healing. No results were noted related to zinc due to insufficient evidence. Although, evidence supports that providing adequate nutrition is important. Oral nutrition is preferred, yet if not possible; provide nutrition by the most appropriate route.

*Oxygenation and perfusion* must be ensured. A primary reason for inadequate tissue oxygen‐ ation is vasoconstriction as a result of sympathetic over activity. Blood volume deficit, pain and hypothermia are common causes of sympathetic overactivity for which the end result could be increased risk for pressure ulcer development.

*Infection* is usually determined clinically [15]. All open wounds contain some degree of bacteria. Healing is most often not impaired until bacteria reach a high colony count. If a wound culture needed, evidence indicates the Levine technique should be used. This technique involves rotating a swab over a 1 cm2 patch of wound with enough pressure to express fluid from the wound for 5 s. A tissue or bone biopsy is the preferred method of identification of osteomyelitis, although biopsies of this nature are not always feasible. Magnetic resonance imaging (MRI) and nuclear medicine tests are more sensitive and specific than conventional plain radiography in identifying osteomyelitis. When bone is exposed in a pressure ulcer, osteomyelitis is often presumed.

An individual with increasing pain may be exhibiting a sign of a wound infection. Other signs of an acute wound infection include erythema around the ulcer's edges, induration, warmth and purulent drainage, no progression toward healing for 2 weeks, friable granulation tissue, foul odor, new necrotic tissue or lack of even spread of granulation tissue across the base of the wound. An individual may also exhibit systemic symptoms of a wound infection including fever, delirium and confusion [15].

*Repositioning* is replacing the term turning. The aim of repositioning individuals at risk for pressure ulcer development is to relieve pressure and/or redistribute pressure. It has been found that a slight change in position can be adequate to aid in relieving pressure. A turn of 30°, as previously encouraged for an individual in bed, for pressure relief, is not always needed to relieve pressure from bony prominences.

There is no research to support repositioning individuals every 2 h will aid in preventing the development of pressure ulcers; this recommendation is based on expert opinion [15]. The frequency of repositioning will, in part, be determined by an individual's tissue tolerance or the ability of both the individual's skin and its underlying structures to withstand pressure without an adverse effect.

As a provider or caregiver, when an individual at risk for pressure ulcer development is in bed, avoid positions with the head of the bed elevated to the point in which excess pressure and shear are applied to the sacrum and coccyx. This is most often any point beyond 30°.

In the seated position, the greatest exposure to pressure is to the ischial tuberosities. The area of the ischial tuberosities is relatively small; therefore, the pressure will be high. Without pressure relief, a pressure ulcer will develop quickly.

If a patient has a reddened area as a result of a previous episode of pressure loading, it is not advisable to position the individual on the same body surface. The reddened area indicates the body has not recovered from the previous position on the body surface and continues to require relief from the pressure load.

If heels are left in contact with a surface for a prolonged period of time, it is not unusual for heel pressure ulcers to develop due to the significant volume of bony structure in relation to the soft tissue in the heel. For the protection of the heels or treatment of heel, pressure ulcers assure that heels are elevated off any surface. Heels should be elevated so as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. To avoid obstruction of the popliteal vein, which begins behind the knee, which may lead to a deep vein thrombosis, care must be taken to not hyperextend the knee.

and hypothermia are common causes of sympathetic overactivity for which the end result

*Infection* is usually determined clinically [15]. All open wounds contain some degree of bacteria. Healing is most often not impaired until bacteria reach a high colony count. If a wound culture needed, evidence indicates the Levine technique should be used. This technique

from the wound for 5 s. A tissue or bone biopsy is the preferred method of identification of osteomyelitis, although biopsies of this nature are not always feasible. Magnetic resonance imaging (MRI) and nuclear medicine tests are more sensitive and specific than conventional plain radiography in identifying osteomyelitis. When bone is exposed in a pressure ulcer,

An individual with increasing pain may be exhibiting a sign of a wound infection. Other signs of an acute wound infection include erythema around the ulcer's edges, induration, warmth and purulent drainage, no progression toward healing for 2 weeks, friable granulation tissue, foul odor, new necrotic tissue or lack of even spread of granulation tissue across the base of the wound. An individual may also exhibit systemic symptoms of a wound infection including

*Repositioning* is replacing the term turning. The aim of repositioning individuals at risk for pressure ulcer development is to relieve pressure and/or redistribute pressure. It has been found that a slight change in position can be adequate to aid in relieving pressure. A turn of 30°, as previously encouraged for an individual in bed, for pressure relief, is not always needed

There is no research to support repositioning individuals every 2 h will aid in preventing the development of pressure ulcers; this recommendation is based on expert opinion [15]. The frequency of repositioning will, in part, be determined by an individual's tissue tolerance or the ability of both the individual's skin and its underlying structures to withstand pressure

As a provider or caregiver, when an individual at risk for pressure ulcer development is in bed, avoid positions with the head of the bed elevated to the point in which excess pressure and shear are applied to the sacrum and coccyx. This is most often any point beyond 30°.

In the seated position, the greatest exposure to pressure is to the ischial tuberosities. The area of the ischial tuberosities is relatively small; therefore, the pressure will be high. Without

If a patient has a reddened area as a result of a previous episode of pressure loading, it is not advisable to position the individual on the same body surface. The reddened area indicates the body has not recovered from the previous position on the body surface and continues to

If heels are left in contact with a surface for a prolonged period of time, it is not unusual for heel pressure ulcers to develop due to the significant volume of bony structure in relation to the soft tissue in the heel. For the protection of the heels or treatment of heel, pressure ulcers

patch of wound with enough pressure to express fluid

could be increased risk for pressure ulcer development.

involves rotating a swab over a 1 cm2

336 Wound Healing - New insights into Ancient Challenges

osteomyelitis is often presumed.

fever, delirium and confusion [15].

without an adverse effect.

to relieve pressure from bony prominences.

pressure relief, a pressure ulcer will develop quickly.

require relief from the pressure load.

*Physical condition*s of certain populations require additional care in positioning. These populations include those with spinal cord injuries, those that are insensate, older adults, individuals that have sustained hip fractures or those that do not maintain a healthy lifestyle.

*Support surface* use has been validated in studies for the prevention of pressure ulcers in high‐ risk individuals and for the treatment of individuals with pressure ulcers. A support surface reduces pressure by spreading the tissue load over a larger area, thus decreasing the load over bony prominences. A support surface also manages the microclimate including moisture and temperature.

Support surface selection is based on mobility, comfort and circumstances of care. In a home setting, consideration is given to the structure of the home including width of doors, power supply and available ventilation for heat from the motor as these factors relate to the support surface to be utilized. If a spouse or significant, other will share the bed consideration should be given to his or her comfort also.

Regular foam does not distribute patient weight uniformly and may worsen or cause pressure ulcers. A higher specification foam mattress is more effective in preventing pressure ulcers

When an individual is placed on a low‐air loss, surface consideration must be given to the linens and pads used on the surface. Linens and pads should not be of materials that will block the air flow.

An issue that can negatively impact an individual at risk for pressure ulcer development or with a pressure ulcer that is related to any support surface is bottoming out. Bottoming out occurs when an individual's pelvic region or buttocks sink down and the support surface no longer provides adequate redistribution of pressure. An assessment for bottoming out can be performed with a hand check. Place a hand, palm side up under the support surface directly below the individual's buttocks region. If the individual can feel your hand or if less than an inch of support material is evident, the individual has bottomed out and the surface should be replaced [16].

*Physician consults* are generally part of a comprehensive treatment plan for individuals with pressure ulcers. Specialists may be consulted to debride wounds or with more complex wounds to perform flap procedures. Infectious disease physicians may be consulted to provide input or to monitor infected wounds especially if osteomyelitis is suspected or confirmed.

*Education* of providers, caregivers and individuals with pressure ulcers is a vital component to any prevention or treatment plan. Without adequate education, failure of a plan is probable. Education of providers should include how to complete a comprehensive skin and wound assessment as well as documentation of the assessments. Providers also require education on the facilities process for wound care treatment, including the principles of wound care and the products available on the wound care formulary.

Caregivers or the individual with a pressure ulcer need to be educated on the cause of the pressure ulcer, the contributing factors, prevention measures, proper nutrition, appropriate wound treatment and appropriate times to contact a provider. Education should include materials in a format understandable for the caregivers and individuals. For individuals with chronic conditions, such as spinal cord injuries, there are often times formal education programs in rehabilitation centers. It is also common to request a caregiver to receive education in the hospital prior to a patient being discharged. Education is crucial to an effective preven‐ tion and treatment plan.
