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Phase-specific
wound managementof decubitus ulcer
medicaledition
Wound Management
The HARTMANN medical edition
series of publications deals with
current subjects from the areas
of medicine and nursing.They emphasise not only basic
knowledge, but also present
specialist and interdisciplinary
developments. The information
goes beyond the products and
is particularly important.
At a time of rapidly evolving
scientific knowledge, information
must above all be up to date.
With this in mind, this series of
books aims to be a source of
advice not only for experiencedworkers. Those who are approach-
ing new areas of medicine and
nursing for the first time are
shown modern treatment methods
and are given useful tips.
PAUL HARTMANN AG
P.O. Box 14 20
89504 HeidenheimGermany
ISBN 978-3-929870-68-8 B34(0708)086XXX/X
HARTMANN
medicaleditionPhase-specificwoundmanagemen
tofdecubitusulcer
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Phase-specificwound managementof decubitus ulcer
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[2.3]
Published by
PAUL HARTMANN AG
89522 Heidenheim
Germany
http://www.hartmann.info
Concept, design, editing and
production:
CMC Medical Information
89522 Heidenheim
Germany
Scientific supervision:
Prof. Dr. med. Walter O. Seiler,
University Geriatric Clinic;
Basel Cantonal Hospital
Friedhelm Lang,
Head of Surgical Department
Leonberg District Hospital
PAUL HARTMANN AG
May 2008
2nd edition
ISBN 978-3-929870-68-8
Translated from the German
edition (ISBN 978-3-929870-62-6)
Paper bleached by a chlorine-free
process
Table of contents
Preface 5
Development of decubitus a multifactorial process 6
Common sites of decubitus ulcer formation 9
Decubitus hazards and risk factors 10 Classification and degrees of severity of decubitus 18
Management of decubitus general principles 20
Relief of pressure as the basis of all treatment 27
Phase-specific moist wound treatment 30
Ident if icat ion and treatment of fac tors in terfering with wound heal ing 39
Hydroactive wound dress ings for phase-specific, moist wound treatment 46
TenderWet wound pad with superabsorber 48
Sorbalgon calcium alginate dressings with excel len t con formabil it y 53
PermaFoam hydroactive foam dressing 57
Hydrocoll absorbent hydrocolloid dressing 60
Hydrotul hydroactive impregnated dressing 63
Hydrosorb transparent hydrogel dressing 65
Hydrosorb Gel for dry wounds rehydration 68
Atrauman Ag silver containing ointment dressing 69
Zetuvit Plus wound dressing for heavily exuding wounds 70
Nursing activities for decubitus prophylaxis 78
Supplementary aids for treatment and nursing care 81
Glossary and list of key terms 85
References and list of illustrations 87
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[4.5]
Preface
One of the most serious complications of immobility is the
development of a decubitus ulcer (pressure ulcer, pressure
sore). For the person affected, it is always a serious health
impairment, quite apart from the enormous amount of
nursing input and cost involved in treating pressure sores.
The problem of pressure ulcer impacts all areas of nursing
care and it has come to be regarded as an indicator of the
quality of nursing care if a pressure sore does not develop.
Under this aspect, increased attention has therefore been
devoted in recent years to the problems associated with
pressure sores. It has been attempted in scientific and clin-
ical studies to elaborate guidelines for practicable prophy-
lactic and therapeutic activities and establish them as
standard practices.
Despite these efforts, pressure ulcer with an annual inci-
dence of 150,000 cases in Stages III and IV still remains a
major problem for a number of reasons. The growing num-
ber of elderly and aged persons of restricted mobility and
often pronounced multimorbidity is a significant factor in
this respect. Especially in the elderly, the management of
pressure ulcer presents a challenge which all too often
remains unmastered.
This HARTMANN medical edition provides essential know-
ledge relating to the pathogenesis of pressure ulcer andsets out successful therapeutic principles which, if applied
consistently, promise good prospects of a cure. It should
nevertheless be emphasized that the management of decu-
bitus ulcer requires both knowledge and skill and a high
degree of discipline on the part of all those involved in
delivering wound management. In many cases, traditional
methods and approaches have to be reconsidered; the
widespread practice of polypragmasy is to be avoided in
favour of consistently structured therapeutic concepts.
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Development of decubitus a multifactorial process
Immobility and the resulting abnormally long period ofexposure to pressure is without doubt the central causalfactor in the pathogenesis of pressure ulcer.
However, a large number of other risk factors specific toindividual patients also contribute to the development ofpressure sore, which makes the process highly complex anddifficult to define. Nevertheless, a program of treatment andnursing care will attempt to address the patients needs ona holistic basis and not merely treat the pressure ulcer as anisolated phenomenon.
A decubitus ulcer is defined as damage to the skin result-
ing from persisting local exposure to pressure. Its process
of development may be outlined in the following general
terms:
When sitting or lying, the human body exerts pressure on
the surface supporting it, which in turn exerts counterpres-
sure on the area of skin bearing upon it. The degree of
counterpressure varies depending on the hardness of thesupporting surface, but is usually above the physiological
capillary pressure of approx. 25-35 mmHg arterial. For
short periods, the skin can tolerate exposure to even high-
er pressures. If the pressure persists, however, compression
of the capillaries carrying the blood in the area of skin
affected results in a reduction of blood flow and oxygen
deficiency (hypoxia). The body responds to this incipient
damage by producing pressure pain as a warning sign,
which causes a healthy person capable of movement to
change position to relieve the load on the compressed
area of skin. Even slight movements are sufficient to inter-
rupt the exposure to pressure and stimulate the impaired
blood circulation back into activity. This pressure pain
mechanism also functions involuntarily during sleep, which
is why persons capable of movement do not develop a
pressure sore.
If these persons are unable to perceive the warning pain,
however, for example because of unconsciousness, anes-
thesia, severe dementia and/or if they are no longer strong
enough to move unaided in response to pain, the com-pression of the skin continues. The impairment of blood
circulation worsens and leads to an accumulation of toxic
metabolism products in the tissue accompanied by an
increase in capillary permeability, vasodilation, cellular
infiltration and edema.
If the pressure on affected area of skin is then removed
completely, the cells are still capable at this point of regen-
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erating completely because the inflammatory responses
promote the elimination of the toxic metabolism products.
If exposure to pressure remains, however, the worsening
ischemia and hypoxia result in irreversible death of the
skin cells with necrosis and ulcer formation.
The main causes of pressure ulcer are thus the factors
pressure x time acting on a given area of skin.
Clinically relevant factors in this respect are the degree of
pressure and the length of time. A high degree of pressure
results in tissue damage sooner than a low degree. As
regards the factor time, high pressure peaks over a short
period are well tolerated by the skin. In contrast, persistingpressure only slightly above the capillary pressure damages
the skin after only a few hours. This fact has practical
consequences: For prophylaxis, patients at risk of pressure
ulcer should be repositioned after a period of not more
than two hours.
It should always be remembered, however, that this aver-
age tolerance range of the skin is subject to considerable
variations which are determined by the individual patients
Causes of pressure sore:
For short periods, the skin can
survive exposure even to heavy
pressure without being damaged.
If the pressure persists, however,
the affected skin cells become
completely ischemic because of
the increasing impairment of
blood circulation and the skin
cells die.
risk factors such as the degree of immobility, the condition
of the skin, various basic illnesses etc. What specific risk
factors are involved and what role they play in causing
pressure sores are considered in the section Decubitus
hazards and risk factors on page 10 onwards.
Common sites of decubitus ulcer formation
Depending on where the skin is exposed to pressure, a
pressure ulcer can develop anywhere on the body. Therisk is greatest at those sites, however, where the bearing
pressure of the body and the counterpressure exerted by
the supporting surface act perpendicularly on an area of
skin located over convex skeletal regions which have little
pressure dispersing elastic muscle and subcutaneous fatty
tissue. Accordingly, the classical sites of predilection
(about 95 % of all pressure sores develop here) are the
sacral region, the heels, the ischial bones, the greater
trochanter and the lateral malleoli.
Pressure / pressure exposure time
local impairment of blood flow
oxygen deficiency / increase in toxic
metabolism products
increase in capillary permeability,
vascular dilatation, cellular infiltration,edema formation
blister formation
complete ischemia,
irreversible death of skin cells
Ulcer / necrosis
Examples of classical sites of
predilection for pressure sores:
1) Sacral region
2) Heel
3) Trochanter
4) Lateral malleolus
1 2
3 4
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Another characteristic feature of pressure acting on convex
bony contours is that the pressure increases from the
larger skin surface towards the deeper-lying convex bone
surface. This results in necroses in the subcutaneous fatty
tissue and muscles until, often not until several days have
passed, the skin ulceration becomes apparent.
This lesion may be relatively small and does not always
reflect the already considerable damage in the deeper
regions. Sometimes the skin shows only reddening andslight damage of the epidermis (closed decubitus).
Besides the pressure acting perpendicularly on an area of
skin, shear forces are probably also involved in causing
pressure sores. Shear is a term denoting tangential shifts
in the skin layers in relation to each other, which also
constrict and compress the blood vessels. Tangential forces
may be expected to arise particularly in the sacral region,
for example when the patient is pulled instead of lifted
into a new position or slides in bed due to inadequate
support for the feet.
Experimental studies on the effects of perpendicularly
acting shear forces allow the conclusion that when a
combination of shear forces and pressure is present, even
slight pressure is enough to reduce the oxygen partial
pressure in the tissue to a critical level (Bennet et al., von
Goosens et al.).
Decubitus hazards and risk factors
The most important risk factor is immobility, since it iscausally related to the duration of pressure exposure. The
hazard increases with the patients degree of immobility.
The commonest pressure
sore localisations
Pressure ulcer develops preferentially over bony prominences hardly
cushioned by muscle and subcutaneous fatty tissue. These are in dorsal position: sacral bone and coccyx, heels and Achilles tendons,
elbows, shoulder blades and occipital bone in abdominal position: frontal bone, elbows, breastbone and costal
arches, iliac crest, kneecaps and tips of the toes in lateral position: great trochanter, ear and zygomatic bone, lateral
ribs, shoulder joint, iliac crest, inner and outer knee joint, calf bone
and lateral malleolus in sitting position: ischial tuberosity, occipital bone, spine and heels;
if poorly supported, there is also a potential hazard from shear forces
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Development of decubitus [12.13]
Total immobility: If spontaneous movements are no
longer possible, the patient is absolutely at risk. Total
immobility is seen, for example, in unconscious, anes-
thetised or completely paralysed patients. The patients
age is irrelevant.
Relative immobility: A high hazard potential is present
because spontaneous movements are more or less re-
stricted, for example due to sedation, fractures, severepain, multiple sclerosis, paraplegia, hemiplegia and
disorders of sensitivity of widely varying origin, such as
polyneuropathy.
It should especially be remembered that the risk factor
immobility is influenced by general nursing care activities
and is thus inevitably subject to diurnal variations. For
example, whereas the immobile patient is repeatedly
moved during the day for basic care activities and feeding,
during the night there is usually a critically long period of
immobility. These problems are observed especially in
association with age related reductions in mobility, which
also results in a critical decrease in spontaneous body
movements (motility) during the night. When additional
diseases are present, such as fever (pneumonia) or severe
pain, the number of nocturnal body movements may
decrease to practically zero, and without prophylaxis the
patient is at risk of developing a pressure sore.
Secondary risk factors
Further secondary risk factors include all states and illness-es which affect especially the function and resistance of
the skin. The skin then becomes more sensitive to pressure
and even brief periods of exposure to pressure can result
in damage.
These risk factors include:
Insufficient blood supply to the skin: Insufficient blood
supply to the skin means a reduced supply of oxygen and
impaired metabolic processes in the skin cells, with the
result that the skins tolerance of hypoxia also decreases.
Blood perfusion can be impaired by a multiplicity of fac-
tors, such as hypovolemic, cardiogenic or septic shock,
low blood pressure, dehydration, heart failure, diabetes
mellitus, arteriosclerosis etc.
Fever: Fever leads to an intensified metabolism of the
skin cells and an increased oxygen demand, as a result of
which inadequate blood perfusion already occurs at
subdecubitogenic pressures. Moreover, in febrile states the
immobility of geriatric patients is often worsened, and
fever is therefore classified as the most important second-
ary risk factor for this patient population.
Incontinence: Moisture and the aggressive decomposition
products of urine and/or feces irritate and soften the skin,
which is also highly bacterially contaminated. If these
effects are not mitigated by the use of adequate skin care
and provision of appropriate aids, the upper layers of skin
become macerated, lowering the skins resistance to
pressure. Incontinence is thus another risk factor affecting
especially elderly, bedbound patients. It is, however, incor-
rect to assume that incontinence alone can cause a pres-
sure sore. The causal factor in pressure ulcer is pressure,
and incontinence is a contributory factor.
Debilitated general condition: Chronic or severe illness-
es, malignant processes, infections, malnutrition character-
ized by protein, vitamin and zinc deficiency, anemia, exsic-
cosis, cachexia etc. also increase the risk of pressure sore.
Many of the diseases greatly restrict the patients mobility/
motility and impair the skins metabolism.
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Development of decubitus [14.15]
Physiological aging of the skin: Independently of co-
existing diseases, geriatric skin is itself a risk factor for
developing a pressure ulcer. The age related depletion of
cellular and fibrous elements makes the skin generally
thinner, and the skins connective tissue loses elasticity. As
a result, the skins ability to tolerate mechanical loading
decreases, and exposure to pressure can lead to the for-
mation of a pressure ulcer within a very short time.
Operation-specific risks
The primary causes of intraoperatively acquired pressure
ulcer are essentially the same as those in other areas of
medicine and nursing: pressure (poorly padded or
unpadded operating tables acts over a period of time
(operation time) on certain areas of the patients skin and
damages them. However, there are also secondary, opera-
tion-specific risks due firstly to patients themselves and
secondly to the surgical procedure. Besides the factors
already described, such as effects of acute and systemic
diseases, fever, age etc., risks presented by patients them-
selves include existing skin damage, e.g. due to confine-
ment to bed before the operation or extension treatment
until the patient is capable of being operated.
Risks arising during the surgical procedure may include:
anesthesia-induced loss of skin tone, incorrect reposition-
ing (especially of the extremities, which may lead to
extremely high pressure points), extreme shear forces and
exposure to pressure during treatment of fractures on the
extension table, assistants leaning on the patient for sup-port, patient hypothermia, incorrect use of disinfectants
(especially in the coccyx region, which can also lead to
excessive cooling of the skin because iodine- and alcohol-
containing disinfectants collect here at the lowest point),
long vessel clamping times or excessively long bloodless
times.
Risk factors for decubitus
Primary risk factors that reduce motility and lead to total/relative immobility
Secondary risk factors that especially reduce tissue tolerance
Neurological disorders with paralysis (all): cerebrovascular stroke, hemiplegia, hemiparesis, paraplegia,
tetraplegia, comatose states of any origin
Surgical interventions: anesthesia (premedication, anesthesia, recovery phase), long operation times
Psychiatric illnesses and psychotropic medications: acute psychoses such as catatonia and acute
depression, sedative medications like neuroleptics, benzodiazepines and similar
Consumptive diseases and severely painful states
Factors reducing intravascular pressure
Arterial hypotension: shock (hypovolemic, septic, cardiogenic), overdose of antihypertensive agents
Dehydration: diuretics, diarrhea, summer heat
Factors reducing oxygen transport to the cell
Anemia: Hemoglobin < 9 g/dl
Peripheral arterial occlusive disease
Diabetic microangiopathy
Hypotension, bradycardia
Hypovolemic shock
Factors increasing oxygen consumption in the cells
Fever: > 38 C
Hypermetabolism
Infections, cytokinemia
Factors resulting in nutrient deficiency in the cells
Malnutrition: deficiency of protein, vitamins, minerals, trace elements
Cachexia: immobility due to muscular weakness and catabolism
Lymphopenia associated with malnutrition: immune deficiency, disorder of wound healing
Factors weakening the skins resistance
Geriatric skin: thin, atrophic, with few immune cells Skin diseases: eczema, candidiasis
Dry, cavernous skin: promotes bacterial and fungal skin infections
Pressure-damaged, reddened skin: as a sign of harmful shunt circulation
Macerated, softened skin: in incontinence due to breakdown products of urine and feces
Heat, inflammatory reddening: circumvention of nutritive microcirculation
Steroid induced skin atrophy: thin, easily injured skin
(Source: Seiler, 2002)
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Development of decubitus [16.17]
Assessment of hazard from pressure ulcer
Estimating each patients risk of developing a pressure
ulcer is the first step in planning of prophylaxis.
This activity may be assisted by using various rating scales
such as the Norton scale, the Waterlow scale or the
Braden scale. In Germany, the extended Norton scale is
widely used in medical nursing, while the Waterlow scale
relates more specifically to the risks of surgical patients.
The Braden scale is used more commonly in the USA.
Common to all these scales is that they take similarly into
account the patients mental and physical state as well as
their level of activity and mobility, and are thus all useful
instruments. It should be noted, however, that the assess-
ment of hazard from pressure ulcer and hence the delivery
of adequate prophylaxis should not only begin at the stage
when reddening has already developed at the risk sites.
Furthermore, the points score should be checked at regular
intervals to allow timely identification of changes and
a suitable response to be made in terms of modifying
activities. The assessment of pressure ulcer hazard is thus
part of a thorough program of documentation.
Physical state Incontinence Activity Mobility Psychological
state
4 good 4 none 4 no assistance
required
4 completely 4 clear
3 fair 3 sometimes 3 possible with
assistance
3 hardly
restricted
3 apathetic /
disinterested
2 poor 2 usually urine 2 wheelchair
required
2 very restricted 2 confused
1 very poor 1 urine and
feces
1 bedbound 1 completely
restricted
1 stuporous
Willingness to
cooperate
Age State of the skin Concomitant diseases
4 completely 4 < 10 4 normal 4 none
3 few 3 < 30 3 scaling dry 3 immune weakness, fever,
diabetes, anemia
2 partially 2 < 60 2 moist 2 MS, Ca, elevated hematocrit, obesity
1 none 1 60 1 allergy wounds,
fissures
1 arterial occlusive disease
According to the original Norton scale (above) patients with
a points score of 14 and less are to be classified as being at risk
of developing a pressure sore. In the extended Norton scale
(original scale above + extension below, devised by C. Bienstein
et al.) which allows a more differentiated assessment of the
patients status, a risk of pressure ulcer is present at a score of
25 points and less. Prophylactic measures must be planned andimplemented immediately.
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Development of decubitus [18.19]
Classification and degrees of severity of decubitus
Considering the origins of pressure ulcer, it is clear why
the ulceration develops in stages: The longer the area of
skin is exposed to pressure, the more severe the tissue
damage becomes.
The classification of degrees of severity is therefore based
on an evaluation of which layers of skin have already been
destroyed by the pressure damage. Various decubitus clas-sifications are used, such as Daniels classification into five
degrees of severity, which is used particularly in the surgi-
cal field, or the most commonly used classification into
four degrees of severity developed by the National Pres-
sure Ulcer Advisory Panel in 1989.
Stage I: Sharply defined area of reddening on intact skin
that, when pressed, is non-blanchable. Indicative signs
may also include hyperthermia of the skin, induration or
edema, and persons with dark skin coloration may show
depigmentation. With consistent pressure relief the red-
dening pales after several hours or days, depending on the
severity of the prior impairment of blood perfusion.
Stage II: Partial loss of epidermis as far as the dermis.
This is a superficial ulcer which may manifest clinically as
an abrasion, blister or shallow crater.
Stage III: Damage to all layers of skin (epidermis, dermis
and subcutis), which may extend as far as the fascia
beneath the skin, although the fasciae are not yet affect-ed. Clinically, the pressure ulcer looks like an open sore
with or without undermining of the surrounding tissue.
Classification of the severity of
pressure ulcer is based on which
tissue layers have already been
destroyed by exposure to pressure.
Stage IV: Loss of skin involving the entire skin thickness
with extensive tissue necrosis and damage to muscles,
tendons and bones. Undermining and pocket formation
are also commonly seen.
Identifying the current stage of the ulceration may be
difficult in practice. For example, skin damage in Stage I
is often not reliably assessed, especially in patients with
dark skin pigmentation. As already mentioned, a Stage I
may already be a sign of deeper lying damage in the form
of a closed decubitus, for example secondary to intraop-
erative exposure to pressure. An ulcer covered with scaband necrotic debris may also impede correct evaluation
unless the devitalised tissue has first been removed.
The assessment of pressure sores may also be difficult in
patients with plaster casts and other orthopedic devices.
Epidermis
Dermis
Subcutis
Muscles,
Tendons,
Bones
Stage I
Stage II
Stage III
Stage IV
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Management of decubitus [20.21]
Management of decubitus general principles
A decubitus ulcer not infrequently takes many months toheal and in elderly persons often presents a challenge thatremains unmastered. Not least, this may be because of the
extreme difficulty in translating the complexity of pressureulcer causation and chronic wound healing into easilyunderstandable, standardized therapeutic concepts.Medicine and nursing are therefore called upon to developa treatment which as far as possible takes into account theindividual patients specific disease and life circumstances.
Because so many influencing variables and risk factors
are present concurrently and have to be given adequate
consideration in the management of pressure sore, it is
recommended to pursue a consistent approach based on
a treatment schedule. This schedule should not be seen as
a rigid structure, but should rather take the form of a care-
fully assembled check list helping to ensure that nothing
is overlooked. A quality assured management program
will include the following steps: Initial assessment of the overall situation, both of the
local state of the ulcer and the patients general status
Completely relieving the pressure on the damaged area
of skin to restore the blood supply.
Phase-specific moist wound treatment with debridement
and infection control; the possibilities of plastic surgical
defect coverage are to be explored and applied if
appropriate
Adjuvant therapies to improve the patients general
condition and nutritional status and to provide ade-
quate pain control; factors interfering with wound
healing are to be treated.
Careful documentation for quality control and security
under liability law aspects.
Assessment of decubitus ulcer
In the initial assessment, the ulcer is evaluated according
to localization, stage, size (length, breadth, depth), pocket
formation, undermining, exudate flow etc. The schedule
provided on page 25 offers a possible approach to initial
assessment. The ulcer localization is sketched in thedrawing field. It is also recommended to include a colour
photograph of the ulcer in the documentation.
To exactly determine the size and volume of an ulcer,
volumetric measurement of the wound is a practicable
approach requiring little time and effort. The wound is
covered with a foil and filled with sterile liquid (e.g.
Ringers solution) using a syringe.
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Initial assessment of overall situation
Causal therapy
Local ulcer therapy
Adjuvant therapies
Treatment
Ulcer healing?
Localization of the ulcer, severity, general
condition of the wound
Evaluation of the patients status, compliance
Complete relief of pressure to restore the blood
supply throughout the treatment period until the
ulcer has healed
Adequate surgical debridement
Infection control, when appropriate
Moist dressing treatment for further wound
cleansing, conditioning and epithelisation
Plastic surgery techniques as appropriate
Improve the general condition
Improve the nutritional status
Pain management
Identify local and systemic factors interfering
with wound healing and eliminate them as far
as possible
Course of treatment for decubitus ulcer supervision
and continuation of therapy according to treatmentschedule
Careful monitoring of activities (especially whether
pressure relief is adequate)
Management of decubitus [22.23]
Volumetric measurement of the
wound is an exact and simple
method of determining the size
and volume of a wound.
The wound is covered with a foil
(left) and filled with sterile liquid
using a syringe(right).The number
of injected ml or ccm correspond
to the volume.
The injected ml or ccm represent the volume. Volumetric
measurement should also be performed repeatedly during
wound healing, since the values recorded are prognostically
valuable and represent valuable objective data for inclusion
in case records. As a positive secondary effect, volumetric
measurement is also useful as a form of wound irrigation.
If it is known under what circumstances and through the
application of what pressure the ulcer developed, these
details are also to be entered in the initial assessment:
For example, application of pressure during surgery, inassociation with a febrile disease, as the result of a fall and
lying too long at home etc. This information is particularly
important for assessing the continuing risk of developing
a pressure sore.
Assessment of the patients status
The assessment of the patient should include the general
condition, possible complications and concomitant dis-
eases, the nutritional status, the severity of any pain, but
also a careful inventory of the psychosocial situation.
General physical condition: Wound healing is not mere-
ly a local process, but is linked to processes in the entire
body on many levels; consequently, an improvement in the
patients general condition can have a major influence on
wound healing.
yes
no
Course of treatment
for decubitus
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Management of decubitus [24.25]
Depending on the patients age and illness, however, an
improvement in the general condition cannot always be
achieved within a short time, and may even be severely
impaired, for example in multimorbid geriatric patients.
In practice, the necessary data can be obtained from the
patients medical record and if not, are to be elicited by
taking a careful and comprehensive medical history and
conducting a physical examination.
With pressure ulcers, moreover, the physician should be
alert to the possibility of complications, such as endo-
carditis, meningitis, septic arthritis, pocket and abscess
formation, malignant processes in the ulcer area, and for
systemic complications of the topical therapy, such as
iodine toxicity or allergy. Serious complications associated
with infection include osteomyelitis, bacteremia and
generalized sepsis.
Nutritional status: Numerous studies have established
a relationship between the poor healing tendency of pres-sure sores and malnutrition. Cachectic states associated
with protein deficiency, however, are observed particularly
often in elderly persons, and the nutritional status should
therefore be evaluated at regular intervals in these cases.
Elderly patients are often also suffering from zinc deficiency
which can also lead to delays in wound healing and
should therefore be checked.
Malnutrition should be treated, taking into account the
patients wishes, by providing adequate dietary intakewith an increased protein content and sufficient vitamins
and minerals. The requirement for nutrients in illness and
catabolism in the elderly is reported as follows per kilo-
gram of body weight and per day (Seiler, 2001): 30 to
40 kcal, 1.5 g proteins, 1.0 g fats, 10 mg vitamin C, 15 mg
calcium, 0.5 mg zinc, vitamin B12 parenterally substituted
(target dose 10 mg total or 0.15 mg per kg body weight
within one month; Interval: every 3 days 1 mg i. m.)
Record form for assessment of decubitus
Name
Age
Date / time of recording
Size
Length breadth depth
Severity / structures affected
Stage I: skin reddening with intact epidermis
Stage II: superficial ulcer, partial loss of epidermis as far as dermis
Stage III: deep, open ulcer, damage to all skin layers as far as the fasciae
Stage IV: extensive tissue necroses, damage to all skin layers including
muscles, tendons and bones
Yes No
Pocket formation
Undermining
Necrotic tissue: closed black necrotic cap
scab
slimy layers
Exudate: serous-bloody
purulent
Granulation: loose, spongy
red, firm
Epithelium formation visible
Pain
Signs of infection: III sligt reddening
III reddening, swelling, pain
III plus fever, leukocytosis
Causation
General condition / other
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Management of decubitus [26.27]
and a high-dose multivitamin preparation. If normal
dietary intake is insufficient or impossible, a fully balanced
liquiddrinking diet or a parenteral diet shouldbe considered.
Adequate fluid intake should also be ensured.
Pain: Even if patients do not give expression to their pain
or do not react to it, this does not mean that it is not
present. Pressure ulcer is usually associated with chronic,
diffuse pain affecting the entire body and making every
change of position extremely painful. Unfortunately, pain
management is still not always accorded the importance
demanded by many experts. Usually, such treatment
consists merely in the administration of analgesics on
demand. Pain management, however, should aim to
achieve the greatest possible freedom from pain, which
requires the regular administration of individually dosed
analgesics.
Psychosocial assessment: Regardless of whether the decu-
bitus patient is being treated in hospital, in a nursing facil-ity or at home, the same therapeutic principles should be
applied to the same standard quality, since otherwise there
is little prospect of a cure. The individual psychosocial situ-
ation, however, sometimes presents greatly differing base-
line conditions in terms of the patients ability to fully
understand the therapeutic requirements and cooperate
with the treatment. The aim of the psychosocial assess-
ment is therefore to obtain information about the degree
of willingness to cooperate that may be expected from the
patient and his/her relatives and what can be done (e.g.by informative interviews, training, use of suitable aids etc.)
in order to assure consistent adherence to the treatment
and nursing schedule. A realistic assessment of the psy-
chosocial situation is thus of major importance especially
in domiciliary care context. Aspects to be evaluated
include the patients mental state, ability to learn, signs
of depression, the social environment, relationship to the
caring relatives as well as lifestyle and ethnicity related
problems. The resources available for treatment and nurs-
ing are also to be evaluated, e.g. the availability and
specialized qualification of carers, financial resources,
equipment etc. If despite all endeavours it is not possible
to create an environment conducive to compliance with
the treatment and nursing schedule, transferring the
patient to the hospital setting should be considered.
Relief of pressure as the basis of all treatmentDecubitus ulcers develop as the result of unrelieved expo-
sure of the skin to pressure, leading via ischemic processes
to the death of skin cells. The causal principle underlying
all decubitus treatments is therefore to restore the blood
supply to the affected area of skin by providing complete
relief of pressure. Without pressure relief, healing is not
possible, and all other activities are pointless. The pressure
relief is also to be maintained throughout the entire treat-
ment period. Any exposure to pressure, even for a few
minutes, causes new damage and sets back the progress
of healing.
Transcutaneous oxygen measurements on the skin under
simulated and clinical conditions in young volunteers have
shown that adequate pressure relief is followed by imme-
diate restoration of the microcirculation and oxygen supply
of the skin (Seiler, 1993). When pressure relief is assured,
not only oxygen, but also all the other cells necessary for
the repair process as well as the biologically important
substances such as hormones, enzymes, vitamins and
growth factors enter the wound area. For complete press-ure relief, the patient is to be positioned such that he/she
under no circumstances can come to bear weight onto the
wound. Even on a bed fitted with supersoft bedding for
pressure relief, the wound area must be kept free from
contact. The positioning that is possible depends on the
localization of the pressure ulcer (see table). The 30 degree
oblique position is regarded as the position involving the
lowest risk.
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Management of decubitus [28.29]
The 90 degree oblique positioning should no longer be
used, either for prophylaxis or for treatment, because most
of the bodys weight then bears on the trochanter. Even
before beginning any treatment, therefore, the type of
positioning suitable for each patient should be estab-
lished, and should lead to the establishment of binding
guidelines for all those involved in the treatment and
nursing of the patient.
The different positioning techniques require the combined
use of static and dynamic aids. Static aids, such as posi-
tioning cushions, should be selected under specific criteria.
Their elasticity should be such that it is also preserved
under pressure. If the material bunches together, new
pressure points result. Especially when using products for
free positioning, such as seating rings, superficial pressure
distribution must be assured. There is no point in free posi-
tioning individual parts of the body and exposing other
parts to pressure.
The patient must also lie securely and without the risk of
Decubitus localisation Correct positioning Remarks
Right trochanter dorsal position 30 degree
oblique position, left
all lateral positioning
is prohibited
Left trochanter dorsal position 30 degree oblique
position, right
all lateral positioning
is prohibited
Sacral region 30 degree oblique position, right30 degree oblique position, left
135 degree positioning
Heel 30 degree oblique position, right
30 degree oblique position, left
contact-free on special cushions
if absolutely contact-free positioning
is guaranteed, then also dorsal
position is possible
Ischial bone 30 degree oblique position, right
30 degree oblique position, left
135 degree positioning
sitting prohibited, dorsal
position is possible if the
patient is also freely positioned
slipping on the positioning aids. With inexpert positioning,
the unfavourable weight distribution creates shear forces.
For larger decubitus ulcers, patients with multiple risk fac-
tors for pressure ulcer, and postoperatively after decubitus
surgery, anti-decubitus mattresses of the low air loss
type are used to ensure absolutely certain pressure relief.
A rhythm of two hours is prescribed as the time interval
for repositioning. For patients with a very high decubitus
hazard it may be necessary to reduce this interval further.
A certain amount of experience is generally needed toposition patients correctly according to their requirements.
It is by no means sufficient simply to slide a cushion some-
where underneath the patient. Nursing personnel should
be fully aware that positioning is not intended to provide
pressure relief in isolated areas, but is a means of influenc-
ing the patients body feeling as a whole. In the worst
case, inadequate positioning can rapidly give rise to
considerable further impairments such as respiratory or
circulatory problems, stiffening of joints or contractures.
The correct positioning of the
patient depends on the localiza-
tion of the decubitus ulcer.
The basic positioning variants
shown here are also suitable
for prophylaxis.
Examples of positionings for
pressure relief with the aid of
special cushions:Due to its special
design, the cushion bed (left)
offers effective pressure relief for
patients in dorsal position.
At the points where the cushions
meet, deeper areas are created,
so that risk zones such as shoul-
der blades, the bony profile of the
spine, the sacrum, coccyx and
heels are positioned almost com-
pletely free.
For the 30 degree oblique posi-
tioning (right) the patient is
placed on a soft mattress with the
head well supported by a smaller
pillow. The 30 degree oblique
position is created by placing a
long, soft cushion laterally under-
neath the patients back.
The knees can additionally be
padded with a cushion.
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Management of decubitus [30.31]
Phase-specific moist wound treatment
Decubitus ulcer is a secondary healing wound, usually with
a poor healing tendency. Providing adequate phase-specific
support for wound treatment is thus particularly important.
These measures include thorough debridement, continuous
cleansing of the wound, conditioning with formation of
granulation tissue and the promotion of epithelisation.
Also included are measures for preventing and/or control-
ling infection. Moist wound treatment, in which modern
hydroactive wound dressings secure the effectiveness of
the method and facilitate its execution, is now regarded
as the standard therapeutic approach for cleansing and
conditioning wounds and promoting epithelisation.
This conservative management of decubitus ulcer by moist
treatment may under some circumstances be possible up
to Stage III of a decubitus ulcer. Stage IV with muscle and
bone involvement and osseous infection, however, is an
indication for wound closure by flap plasty following
adequate surgical treatment and wound conditioning.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Schematic diagram of the timing of the wound healing phases:
Inflammatory phase:
Cleansing
Proliferative phase:
Fibroblast migration and formation of granulation tissue
Differentiation phase:
Maturation and increasing
wound contraction / epithelisation
Therapeutic principles and the problems involved in plastic
surgical coverage especially in geriatric patients are briefly
described from page 37.
Cleansing phase and debridement
In the cleansing phase, devitalised tissue and microorgan-
isms are removed by autolytic processes. Since the extent
of devitalised tissue in a Stage II to III decubitus ulcer is
so great that wound cleansing cannot be accomplished
by the bodys own resources unaided, however, the wound
requires external assistance in the form of thorough
debridement. This can be accomplished surgically and/or
physically by means of moist wound treatment.
The most rapid method of removing necrotic material is
surgical debridement with a scalpel or scissors. Necrotic
tissue must be surgically excised as soon as possible, since
an infection under a necrotic crust can spread unnoticed
into deeper tissues. The risk of decubital sepsis or
osteomyelitis then increases rapidly. Moreover, necrosesprevent healing since they maintain the chronicity of the
wound.
Necroses are thus always removed. One exception is
necrosis on the heels. This material is only debrided if a
prior angiographic examination has ruled out the presence
of arterial occlusive disease or a recanalisation operation
has been successfully completed.
The indication for, type and proper execution of wounddebridement are activities reserved for the physician in
both the inpatient and outpatient settings. The physicians
obligation to provide a personal service does not however
exclude delegating these activities to assistant personnel
in certain cases, provided he has made sure that the
person entrusted with the task is adequately qualified for
the task.
The more effective the cleansing
of the ulcer, the better the quality
of the subsequent granulation tis-
sue will be. Hydroactive wound
dressings perform valuable service
in this respect.
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Management of decubitus [32.33]
The situation, all too common in clinical practice, of some-
one snipping around at an ulcer, should not in fact occur
if the legal regulations are properly observed.
Surgical debridement should be performed under adequate
anesthesia in the operating room because of the pain
involved and the possibility of complications.
Especially extensive areas of necrosis, but also ulcerations
of as yet unknown depth should be debrided under oper-
ating room conditions. Debridement at the bedside is
increasingly being abandoned. At most smaller ulcers can
be debrided at the bedside, provided that adequate pain
control is provided, e.g. using local anesthetic creams.
If surgical debridement is not possible, for example in very
elderly patients in a poor general condition, patients
receiving marcumar or heparin therapy, patients with fever,
lung inflammation, recent cerebral stroke etc., physical
debridement is the alternative. Physical debridementmeans softening and detaching necrotic material and fibri-
nous layers with the aid of hydroactive wound dressings.
This approach offers several practical advantages:
it is selective, because only devitalised tissue is softened
and detached, while healthy tissue is not traumatised.
Furthermore, the moist wound environment spares the
cells responsible for cleansing and proliferation and pro-
motes their activity. The method is also safe and free from
side effects and easy to perform in all medical and nursing
settings, for instance for the domiciliary care of decubitusulcer.
Course of surgical debridement
under operating room conditions
for a decubitus on the trochanter.
The damage was found already to
extend much more deeply than
suspected of this relatively small
lesion.
However, one disadvantage of the method should be
remembered: Physical debridement is not as rapid andeffective as surgical debridement and cleansing will take a
longer time, a fact which demands a patient and conscien-
tious attitude on the part of the treating person.
Various hydroactive wound dressings are available for the
practical implementation of physical debridement. The
specific modes of action and suitability for different wound
conditions are explained in the descriptions of hydroactive
wound dressings provided on page 46 onwards.
Wound irrigation, for example with Lavasept or Ringers
solution, may be helpful to support moist wound treatment.
This can be done continuously through an indwelling
catheter, e.g. for slimy, infectious wounds, or on changing
the dressing.
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Management of decubitus [34.35]
Infected decubitus with pus for-mation; if bacterial toxins are
transferred through the lymph
tracts and blood stream to other
organs, bacteremia or sepsis may
result. The formation of granulation
tissue can only take place in a
homogeneously moist wound
environment. Promoting and
maintaining this moist wound
environment is therefore the most
important task of a wound dress-
ing in this phase.
Infection prophylaxis and control
Local infection and peri-ulcer bacterial dermatitis are very
common complications. If they are not recognized in time,
acute decubital sepsis or unnoticed osteomyelitis can
develop. Local infection usually presents with the classical
symptoms: reddening and hyperthermia of the area of skin
around the ulcer, burning pain on the ulcer floor and peri-
wound area as well as tenderness and edema at the ulcer
margin and surrounding area. Expected systemic effects
are fever, leukocytosis and elevated C-reactive protein,
although these symptoms are often absent in elderly
patients. A small tissue biopsy for the bacteriological cul-
ture is very helpful, as it allows selective antibiotic therapy
to be prescribed if there is a sudden outbreak of decubital
sepsis.
The prophylactic use of disinfectants often observed in
practice is no longer recommended because of their some-
times considerable inhibitory effects on wound healing and
the toxic properties of some antiseptic substances. If theulcer exhibits clinically overt infection and if antiseptics are
to be used for a short period, when choosing the antisep-
tic it should be ensured that it causes no pain and does
not considerably compromise wound healing. In particular,
an absorption-associated risk should be ruled out, an
aspect of particular importance in deep and extensive
pressure sores with their protracted treatment period.
Even greater problems are presented by the topical use
of antibiotics, a practice now regarded as obsolete. Itinvolves the risk of resistance development and a change
of the pathogens as well as a greater risk of allergy de-
velopment than is the case with antiseptics. Furthermore,
it is difficult to achieve a sufficient active agent concentra-
tion deep inside the wound and to estimate the inhibition
of wound healing processes.
In patients with severe infections, the systemic administra-
tion of antibiotics is indicated, and a microbial determina-
tion and resistance test is to be performed if possible to
optimize the therapy.
The granulation phase
Decubitus ulcer is a wound healing by secondary intention,
which means that replacement tissue, known as granula-
tion tissue, must be produced to fill the defect.
Getting through this phase and supporting the wound in
the best possible manner often presents considerable diffi-
culties in practice because it usually requires much time
and demands absolute consistency in adhering to the
therapeutic concept.
Formation of granulation tissue can only take place if the
following conditions are fulfilled: The ulcer must remain
completely relieved of pressure throughout the entire peri-
od so that blood supply to the wound area remains intact
and is not impaired by renewed exposure to pressure.
The wound floor must never be allowed to dry out and
must be kept permanently moist. If the wound becomes
dry, the cells necessary for vascularisation and tissue
generation die. A moist wound environment, in contrast,
promotes the proliferation of the cells and is thus the best
form of care for the granulation tissue. The available
hydroactive wound dressings make it possible to keep the
wound permanently moist (see description of hydroactive
wound dressings from page 46 onwards).
The wound must be protected against both chemical and
mechanical irritation. Local antiseptics should therefore
not be used in this phase. If certain parts of the wound are
still in the cleansing phase and if they are still to be disin-
fected, particular care should be exercised in the areas
around the granulation tissue.
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Management of decubitus [36.37]
Mechanical irritations occur when the wound dressing
adheres to the wound and newly formed tissue is detached
on changing the dressing (= cell stripping). To prevent this
considerable disruption of wound healing, the wound
dressings used must have atraumatic properties, i.e. they
must not adhere to exuding wounds even during pro-
longed application. All hydroactive wound dressings are
atraumatic and thus also offer the desired safety of wound
care in this respect.
The wound must also be protected against secondary
infections, which is why dressings should always be
changed under sterile conditions. Dressing changes should
also be performed under sterile conditions in the home
care delivery setting. If the pressure ulcer is located at a
site on the body highly subject to bacterial contamination,
e.g. in the sacral region, wound dressings with bacteria-
proof surfaces such as the hydrocolloid dressing Hydrocoll
provide effective protection against infection.
In the endeavour to speed the formation of granulation
tissue until the onset of spontaneous epithelisation, a
large number of topical therapeutic agents are still used in
practice, although scientifically validated studies demon-
strating effectiveness are available for hardly any of these
preparations. The off-label use of these medicinal products
or medical devices without official approval is not without
problems and is only justifiable in a few exceptional cases
after the currently available therapeutic options have been
observed to fail and if their use is expressly allowed by thepatient. As a general principle, powders and pastes, but
also certain preparations in ointment form, should not be
introduced into open wounds. They impede assessment of
the wound and can also impair fluid and gas exchange.
Moreover, interfering residues frequently remain in the
wound when dressings are changed (Winter, 2005). A side
effect free substitute for most of these topical wound ther-
apeutic preparations is permanent moist wound treatment.
The epithelisation phase
Epithelisation by mitosis and migration of epithelial cells
from the wound margin completes the wound healing
process. In this phase too, keeping the wound surface
permanently moist and protecting the young epithelium
from cell stripping when changing dressings are the most
important aspects of treatment, apart from the fact that
complete relief from pressure must continue to be main-
tained.
However, especially decubitus ulcers tend to epithelise
poorly. As Seiler et al. were able to demonstrate in 1989,
epithelial cells in the immediate vicinity of the ulcer margin
show greatly restricted migration. The growth rate was
only 2-7 %, whereas healthy skin usually showed a growth
rate of about 80 %.
During the long chronic course of healing of decubitus
ulcer, the constellation is not infrequently seen that the
wound margins epithelise and protrude inwards. Since nofurther epithelisation can then take place from the wound
margins, the wound margins should be refreshed by trim-
ming with a scalpel or sharp scissors.
Defect coverage by plastic surgery
Open wound management for decubitus ulcer is subject to
complex problems: It causes pain and impairs the patients
already debilitated general condition. In addition, conser-
vative treatment is always protracted, which is not only
unsatisfactory for the patient and therapist but also placesan enormous burden on the health service. A surgical
procedure, on the other hand, offers advantages mainly in
terms of time, relief of stress on the patient and cost-effec-
tiveness. Whenever possible, therefore, not only younger
patients but, increasingly, elderly patients with more
severe decubitus ulcers should benefit from this procedure.
Increasing wound contraction andepithelisation from the wound
margin due to cell mitosis and
migration of epithelial cells com-
plete the wound healing process.
A moist wound environment is
also required in this phase.
f b l i l b f ll f hi l i l l i i d b id l i
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Management of decubitus [38.39]
Plastic surgical coverage of a
large sacral decubitus (case study
by Jian Farhadi, Basel):
Decubitus measuring 7x6 cm after
debridement, dissection of a
perforator vessel from the direct
vicinity of the defect, flap trans-
posed into the defect, gluteus
maximus fully intact, problem-free
closure of graft site. Flap com-
pletely tension-free in the defect
after closure of graft site.
Defect coverage by plastic surgery can only be fully suc-
cessful if the patient is optimally prepared for the proce-
dure. Basically, six principles should be followed, and are
always implemented in the same order: Pressure relief,
debridement, wound conditioning, treatment of risk fac-
tors, plastic surgery and continuation care or prophylaxis.
The indication for operative closure is dependent on a
large number of parameters and is differentiated into vital,
absolute and relative indications. Vital indications for an
emergency operation are septic decubitus and arrosion
bleeding. Although these events are rarely encountered
clinical situations, their recognition and immediate treat-
ment can be life saving. An absolute indication for surgery
is present when bones or joints are exposed or where the
wound extends through to internal organs. Cicatricial
cancer developing from long-standing unstable scar areas
is also an absolute indication for radical debridement and
defect coverage of decubitus. Although cicatricial cancer is
very rare, with chronic wounds a biopsy should be taken
for histological analysis prior to debridement. Relative
indications for surgery are present in Stage III and IV
decubitus ulcers to allow early and timely mobilisation of
patients, spare them pain and also to shorten the input-
intensive period of nursing care.
Identification and treatment of factors interfering
with wound healing
Chronic skin ulcers like decubitus show the typical clinical
signs of impaired wound healing in an area which has
usually suffered major metabolic derangement. The para-
mount aim of every ulcer therapy is therefore to restore
the physiological conditions, since the repair processes of
wound healing can only take place in the correct chrono-
logical sequence if physiological conditions resembling the
normal situation as closely as possible are present in the
wound. If wounds or chronic ulcers heal poorly or not at
all, factors delaying healing are present which prevent
physiological conditions developing. It is therefore an
important aspect of decubitus management to search forsuch interfering factors in each individual patient. If all
the interfering factors can be successfully identified and
eliminated and physiological conditions thereby restored,
healing can begin.
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Management of decubitus [40.41]
General factors interfering
with wound healing
Infections Pneumonia (acute, chronic) Chronic bronchitis Urinary tract infections
(acute, chronic) Osteomyelitis Sepsis Local infection of the ulcer Ulcer necrosis Fever Leukocytosis CRP elevation Lymphopenia
Malnutrition Catabolism Loss of appetite Dehydration Low-protein diet Protein-free diet
Meat-free diet Albumin deficiency Transferrin deficiency Ferritin deficiency Cholinesterase deficiency Low cholesterol Vitamin B12 deficiency Folic acid deficiency Hyperhomocysteinemia Zinc deficiency Iron deficiency Vitamin D deficiency
(Source Seiler, 2002)
Therapeutic options
Therapy of specific underlying
causes, whenever possible, or
optimized treatmentUse of antibioticsRemoving of devitalized tissue
(debridement)Reduction of feverProvision of quality nutrition
Searchfor causesof catabolism Search for cause of
malnutrition (multifactorial):
e.g. gastric ulcer, depression, zinc
deficiency
Causal therapy of malnutrition Optimal diet
Proteins: 1.0-1.5 g /
kg body weight
Calories: 30-50 kcal /
kg body weight
Fats: 30 % of daily calories
Drinking volume: > 20 ml /
kg body weight
Vitamin B12: 10 x 1 mg s.c.
Folic acid 1 mg oral
Zinc (org.) 20 mg / day oral
Iron, always intravenous dose
depending on severity. Fully balanced drinking diet up
to 1500 ml / d
Multivitamin preparation
Calcium-Vitamin D preparation
General factors interfering
with wound healing
Diseases Depression, social isolation Anemia Dehydration Diabetes mellitus Immune weakness Heart failure Renal failure Diseases of the gastro
intestinal tract Paralysis Immobility Nicotine abuse
Medications Corticosteroids Sedative medications Cytostatics
Immunosuppressive agents Toxic topical therapeutic
agents,e.g. hydrogenperoxide
Therapeutic options
Always treat diseases
optimally, since diseases lead
to catabolism Depression: SSRI, care Hemoglobin > 11 g / dlDrinking volume:
> 20 ml / kg body weightDiabetes mellitus: optimal
glucose levelsHeart failure, e.g. no leg
edema!White blood count > 2000
(abs.) Serum zinc > 12 mmol / LMobilise
Always check topical therapeu-
tics and medications for nega-
tive effects on wound healing
Sedative medications immo-bilise and impede pressure
relief
Local interfering factors
(local findings)
Inadequate pressure relief Whitish wound margin Visible, rectangular or round
pressure mark at ulcer margin
due to excessively thick
dressing (> 2 mm)
Necrosis
Slimy coatings Black necrotic crusts Elevated infectious parameters
Local infection Ulcer margin: reddened,
hyperthermic, edematous,
tender painful Elevated infectious parameters
Wound area without
granulation, dried out Wound area dried out Dressing adhering After dressing change:
bleeding sites, tissue sticking to
dressing; pain during and after
dressing change
Toxic topical therapeutic
preparations
The following are toxic for tissue: hydrogen peroxide strong disinfectants
dyed solutions, etc.
Procedure
Optimize pressure relief Use only thin, moist dressings
Debridement Optimize pressure relief Use only thin, moist dressings Systemic antibiotics if infec-
tious parameters elevated
Debridement Keep permanently moist Dressing change 4 x daily
Wound irrigation with Ringers
solution Keep permanently moist with
suitable hydroactive wound
dressings, e.g. hydrocolloid
dressings
Check wound preparations for
topical tissue toxicity
1) Trochanter decubitus with local Further local or systemic factors that interfere with wound
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Management of decubitus [42.43]
1) Trochanter decubitus with local
infection with clearly visible red-
dening and edema (shiny skin);
blackish-yellow necrotic crust,
from under which a drop of pus is
exuding at the right edge
2) Sacral decubitus with multiple
large and deep fistulous tracts;
fistulous tracts always indicate
the presence of osteomyelitis
3) Local infection with Candida
albicans (thrush); typical, the red-dening close to the ulcer edge
4) Whitish, hyperkeratotic lesions
(incipient callus formation) are a
typical sign of insufficient pres-
sure relief on a too firm mattress
1 2
3 4
It is rarely possible to eliminate all interfering factors. For
example, the factor advanced age, which delays wound
healing, cannot be eliminated. Even partially and succes-
sively addressing factors that delay healing, however, canprovide benefits. The search for interfering factors is a task
that should be integrated into the daily routine, since they
are either permanently present or, like fever for example,
come and go. Usually, several factors delay healing in the
same patient.
In decubitus, the recurrent, pressure induced ischemia
predominates as an interfering factor of the first degree.
The most important and most effective means of prevent-
ing ischemia and improving the microcirculation in the
skin areas at risk remains permanent and complete relief
of pressure (see also page 27). Achieving this condition
in practice, however, is not always easy.
Further local or systemic factors that interfere with wound
healing are, to mention only a few: local bacterial and
fungal infection, sepsis, osteomyelitis which is often diffi-
cult to recognise as such due to the paucity of symptoms,
necroses, chronic application of tissue toxic substances,
diabetes mellitus, cytostatics, corticosteroids, dried wound
dressings, malnutrition with zinc deficiency, protein defi-
ciency, the patients mental state, depression, social isola-
tion, fever etc. The elimination of interfering factors thus
represents an attempt to restore the physiological wound
conditions and address the patients needs in a holistic
manner.
Documentation of decubitus management
Exact wound documentation describes all the criteria
applied both for therapy planning and estimating the
prognosis, monitoring of therapy and the progress of
healing. It thus forms the basis of all effective wound
management, but should also be seen and accepted as
an indispensable instrument for assuring the quality oftreatment.
Careful recording of the data serves all those involved in
delivering wound management as a binding guideline and
facilitates adherence to a consistent procedure, starting
with a diagnosis of the cause of the wound, establishing
an adequate causal therapy and evaluating the state of
the wound preparatory to deciding the local wound therapy.
As a result, the persons delivering the treatment address
the wound related problems in a comprehensive manner.
In combination with the search for interfering factors,
this improves the prospects of healing the decubitus more
rapidly.
Wound documentation is also an effective means of reli- a system of documentation may already contain definitive
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Management of decubitus [44.45]
Wound documentation is also an effective means of reli-
ably estimating progress, stagnation or even setbacks in
wound management, and allows therapeutic activities to
be rationally modified whenever necessary.
Above all, wound documentation guarantees the flow of
information between the physician and nursing personnel.
In this way, it can for example be prevented that conflict-
ing activities may be carried out from one dressing change
to another, merely because another person is in charge of
wound care.
Documented evidence that medical and nursing have been
delivered in accordance with current standards has been
made a routine obligation regulated by law, and written
documentation is thusindispensablefor assuring the stand-
ards of medical and nursing performance as required by
(liability) law. Verbal agreements, made for example on
changing from one ward to another or at the ward meet-
ing, are not a suitable means of providing the legallyrequired proof of quality of treatment and care.
Whenever possible, data should be entered in the records
immediately after the wound treatment has been provided.
The state of the wound is then still fresh in the mind of the
person concerned and no important information is lost.
The records are then always up to date during the course
of a shift. The occasionally observed practice of collecting
all the entries and entering them all at once just before
ward transfer is to be rejected as inadmissible and impre-
cise.
A suitable choice of language which exactly describes
the state of the wound is of considerable importance for
the information value of the documentation. In practice,
however, this often causes difficulties and statements are
often imprecise. To eliminate uncertainties in this respect,
a system of documentation may already contain definitive
descriptions of the various parameters which only need
to be ticked off. Alternatively, the descriptions to be used
can be established in the team and laid down as the
standard for the documentation which is then binding
for the wound team.
A particularly effective means of definitively and accurately
recording the course of healing is to include photographic
documentation. Incorrect interpretations of the type that
can arise when wound descriptions are recorded only in
writing, are ruled out. As regards photographic documen-
tation, however, certain legal aspects must be taken into
account, relating mainly to the patients informed consent.
As regards practical implementation, it is important that
photographs documenting the course of wound healing
should always be taken under the same conditions to
allow informative comparisons to be made between photo-
graphic records taken at different times.
All the images must be durable
and not fade and retain their
evidential power even after years
if necessary. Thus the careful
administration of files is necessary.This includes establishment of the
meaningful file designation (thus
e.g. Name_Surname_Date.jpg),
regular backup of all files and,
additionally, filing the hardcopy in
the patient records, if applicable
As regards the aperture setting
used, it should be remembered
that not only the central wound
area but also the surrounding
parts of the body should besharply imaged; a flash may be
used if necessary. The background
should be asneutral as possible,
i.e. without structure (right).
The photographic apparatus
should be as parallel as possible
with its exposure level to the
photographed object. If the
exposure plane and the photo-graphed object are not parallel,
the picture will be distorted
and will not reproduce the size
conditions exactly.
1 2 3
Hydroactive wound dressings The scientific principles of moist therapy were established
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Hydroactive wound dressings [46.47]
Hydroactive wound dressingsfor phase-specific,moist wound treatment
Moist wound treatment is today the standard approach forall secondary healing wounds with tissue formation. It is
particularly successful in the management of chronic problemwounds. Practitioners have at their disposal a range ofhydroactive wound dressings for moist therapy which coverthe entire spectrum of therapeutic requirements in the formof a phase-specific therapeutic system.
The scientific principles of moist therapy were established
by the studies of G. D. Winter (1962, first published in
Nature). This author demonstrated that a moist and
permeable wound dressing and the associated moist
wound healing results in more rapid healing than a dry
wound environment exposed to the air. Moist wound treat-
ment has positive effects on all phases of wound healing.
During the cleansing phase, moist wound dressings
achieve a thorough cleansing of the wound and render
possible mechanical debridement without damaging
cells. Inactivation of immunocompetent cells can also be
avoided by the moist environment (Seiler).
During the granulation phase, a physiological microclimate
similar to a cell culture medium is created within the
wound which encourages cellular proliferation and conse-
quently the formation of granulation tissue. Turner / Beatty
et. al (1990) have reported that permanent moist therapy
causes a significantly more rapid reduction in the size ofthe wound area and a larger amount of granulation tissue.
In the epithelisation phase, the conditions for mitosis and
migration of epithelial cells improve under moist dressings.
This generally results in more rapid epithelisation with
better cosmetic results. Patients frequently report that their
pain is relieved under moist wound treatment.
In addition, the dressing change itself is atraumatic and
causes less pain because modern dressings, as used for
moist wound treatment usually do not stick to the wound,
i.e. have atraumatic properties. At the same time, this
nonstick effect eliminates the stripping off of cell layers
when the dressing is changed the undisturbed state of
the wound so important for healing is preserved.
Tulle bandaging materials adhere
to the wound (above), newly
formed tissue is also detached
when the dressing is changed.
This disruption of wound healing
can be easily prevented by using
atraumatic wound dressings suchas gel forming calcium alginate
dressings (below).
However, the success of moist wound treatment depends ingrowth is possible (3). The moisture and the electrolytes
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Hydroactive wound dressings [48.49]
However, the success of moist wound treatment depends
on a critical prerequisite: the wound requires a permanent,
uninterrupted, balanced supply of moisture. If at any stage
drying out is allowed to occur, the cells inevitably die as a
consequence. Further necroses develop and can even
eventually deepen the wound.
Wound dressings for the moist wound treatment
For practical implementation of the moist therapy is now
the series of hydroactive wound dressings available, by
which can be covered, within the meaning of phase-specif-
ic wound management, the entire scope of the therapeutic
needs.
TenderWet wound pad with superabsorber
TenderWet is an extremely effective wound dressing for the
treatment of chronic, infected and non-infected wounds
during the cleansing phase and at the start of the granula-
tion phase. This high efficiency is attributable to a special
principle of action which allows continuous rinsing ofthe wound.
TenderWet is a multilayered dressing pad containing super-
absorbent polyacrylate (SAP) as the central component
of its absorbent core. The non-medicated superabsorber is
activated before use with an appropriate volume of
Ringers solution which is then supplied continuously to
the wound over a period of hours. The constant delivery
of Ringers solution softens, detaches and rinses away
necrotic tissue (1).
At the same time, however, microbially contaminated
wound exudate is absorbed and bound into the absorbent
core. This exchange Ringers solution is delivered and
proteins are absorbed functions because the superab-
sorber has a greater affinity for the protein-containing
wound exudate than for the sodium-containing Ringers
solution (2) and so the wound exudate displaces the
The principle of action of
TenderWet
1
2
3
ingrowth is possible (3). The moisture and the electrolytes
contained in the Ringers solution, such as sodium, potas-
sium and calcium, contribute to the cell growth.
TenderWet has no contraindications and can also be used
on infected wounds. In certain cases, there is an apparent
increase in the size of the wound during the initial cleans-
ing phase with TenderWet. This means that with this
method devitalised tissue which was not recognisable as
such was removed.
In the case of deep wounds, TenderWet should be packed
in loosely to ensure the direct contact needed for the fluid
exchange. The physical characteristics of the superabsorber
in combination with the outer covering of knitted fabric on
the wound pad give TenderWet the necessary packing
characteristics. With extensive wounds, the TenderWet
wound pads should be applied with a slight overlap the
tiling.
TenderWet comes in a range of presentations and is avail-
able in round and rectangular shapes to meet differing
application requirements.
For greater ease of use, TenderWet and TenderWet 24 are
supplied in already activated form as TenderWet active
cavity and TenderWet 24 active. These active wound pads
are saturated ready to use with Ringers solution and can
be applied immediately. This dispenses with time consum-
ing preparations. Another advantage of the already activat-
ed wound pads is that a much greater volume of Ringers
solution can be introduced into the absorbent core than is
possible with manual impregnation. As a result, the wound
can be kept moist longer.
TenderWet 24 active is already
activated with Ringers solution
ready for use. The integrated pro-
tective layer makes the dressing
well suited for treatment under a
compression bandage.
Moreover, the pads are soft and easy to shape, especiallyTreatment of a pressure sore on
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Hydroactive wound dressings [50.51]
, p y p , p y
in case of TenderWet active cavity, which can be used to
pack even cavernous wounds without difficulty. In con-
trast, TenderWet 24 active should not be packed into the
wound because of its moisture-repellent protective backing
layer.
The classical TenderWet must be saturated with Ringers
solution before use. How much Ringers solution is required
to activate the dressing depends on the size of the com-
press and is indicated on the packing accordingly. For easy
activation of TenderWet (and also of TenderWet 24),
TenderWet solution is supplied in ready to use vials. The
composition of the sterile, pyrogen-free and isotonic solu-
tion corresponds to that of Ringers solution.
TenderWet 24 active and TenderWet 24 are designed so
that the absorbing and rinsing effect is sustained for up to
24 hours. To protect the dressing from strike through,
moisture repellent layer is integrated inside the dressingon the side facing away from the wound. The side of the
compress with the integrated protective layer is identified
by the presence of parallel coloured strips to allow secure
positioning of the wound pad. Because of this protective
layer, TenderWet 24 should not be packed into the wound.
The following applies generally to all TenderWet wound
dressing pads: They are not self-adhesive and require
adequate fixation, e.g. complete-cover dressing retention
with elastic adhesive nonwoven fabric (e.g. Omnifix) or
elastic conforming bandages (e.g. Peha-crepp, Peha-haft).
the heel with TenderWet (Case
study by Antje Wagner,Leinfelden-
Echterdingen): 84-year-old female
patient, coronary heart disease,
arterial occlusive disease, increas-
ing dementia; decubitus on the
left heel. Start of TenderWet treat-
ment on 23 April 99, the necrosis
of the heel extended almost as far
as the bone (Fig. 1). By 22 May
necrotic tissue on the heel hadbegun to scale away. The wound
is well supplied with blood; some
granulation tissue had begun to
form (Fig. 2). Consistently contin-
uing this treatment, the heel sore
was completely clean by 11 June
(Fig. 3). Treatment was continued
unaltered until the wound healed
completely (Fig. 4, 14 August).
Packing of a deep decubiti withgauze strips impregnated with
antiseptics (Fig. 1) does not
always ensure sufficient cleansing,
thus alternatively ensuring of a
quick and thorough debridement
by using of wound pads Tender-
Wet active cavity shall be consid-
ered (documentation of F. Meu-
leneire, Belgium). Preliminary a
palpation by finger is carried out
to determine the size of the
wound cavity, corresponding
marking to the skin surface (Fig.2) and adjustment of a proper
TenderWet compress size (Fig. 3).
TenderWet active cavity can be
well adjusted due to its plasticity
(Fig. 4).
1
3
2
4
1
3
2
4
TenderWet 24 active and Tender-
Wet active cavity are already
activated with Ringers solution
ready for use.
Treatment of a coccyx decubitus Sorbalgon calcium alginate dressings
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1 2
3 4
5 6
Hydroactive wound dressings [52.53]
with TenderWet (Case study by
Eduard Rath, Bernried): 84-year-
old female patient, diabetes
mellitus,compensated heart failure,
poor general condition, pressure
sore in coccyx region, S/P femoral
neck fracture on both sides.
On admissionon 18 March 96, the
pressure sore was necrotic and
purulent with an overt anaerobic
infection, surgical debridementwas performed on 19 March.
On 27 March, treatment of the
wound was changed to the dress-
ing pad TenderWet (Fig. 1),
activated with an antiseptic
instead of Ringers solution
(Fig. 2).
On 9 April, the wound was free
from purulent secretions, clean
granulation tissue was visible
(Fig. 3). Further treatment was
administered using TenderWet
activated by Ringers solution.The buildup of granulation tissue
was continuing.
The superficially damaged areas
of the wound had epithelised
well after three and five weeks
(Fig. 4/5). TenderWet treatment
was continued until 19 June, then
changed to Hydrocoll. Wound size
1,5x3 cm on 26 June (Fig. 6).
Patient discharged from hospital
on 1 July.
with excellent conformability
Sorbalgon is the wound dressing ideally suited for cleans-
ing and for supporting the build-up of granulation tissue
in superficial and deep infected and non-infected wounds.
By virtue of its excellent packing characteristics, Sorbalgon
also provides effective cleansing and conditioning in deep
wounds.
Sorbalgon is a nonwoven dressing made of high-qualitycalcium alginate fibres which are introduced in the dry
state into the wound (1). As they absorb sodium salts,
present for example in blood and wound exudate, the
fibres start swelling and undergo transformation into a
hydrophilic gel which expands and fills out the wound (2).
Since Sorbalgon adapts closely to the wound surfaces,
microorganisms are also taken up deep inside the wound
and are reliably absorbed into the gel matrix (3). This pro-
vides efficient microbial reduction and helps avoid reconta-
mination. Wounds are swiftly cleansed, and Sorbalgon hastherefore proved especially successful in the treatment of
chronic and infected wounds.
Very good wound healing properties of Sorbalgon are
among the other things due to type of suction properties
of calcium succinate fibres. They absorb 10 ml exudates
per gram of weight and thus have very high absorption
capacity. On the other side, the absorption capacity is not
achieved mainly among the fibres as by gauze, but the