Guideline-based and individualized in bio-psycho-social management.

Various primary and secondary risk factors are discussed in connection with the development of decubital ulcers. Depending on the classification of the pressure ulcer, therapy is provided in an outpatient or inpatient setting. Due to the complexity, it is important to include the bio-psycho-social aspects in the treatment concept according to the ICF model. Local wound care should be accompanied by specialized professionals.

Within the framework of evidence-based medicine, international professional societies regularly revise recommendations. In this regard, the European Pressure Ulcer Advisory Panel (epuap.org), the National Pressure Injury Advisory Panel (npiap.com), and the Pan Pacific Pressure Injury Alliance (pppia.org) have published a major update in 2019, which can be viewed digitally. A new revision is planned in 2024 to update the recommendations to reflect new evidence. Although the strength of the recommendations has changed, many basic principles remain similar.

Definition

A pressure ulcer (pressure injury) is localized damage to the skin and/or underlying tissue, as a result of pressure or of pressure in combination with shear forces. Pressure sores usually occur over bony prominences, but can also occur in association with medical devices or other objects.

Newly, tissue tolerance is emphasized in the individual changing situation. This is influenced by, for example, microclimate, blood flow, age, health situation, comorbidities or tissue condition. Among these other factors, which are actually or presumably associated with pressure ulcers; the most common is immobilization [1].

Classification

Pressure ulcers are classified into four grades. In addition, two categories are described to integrate deep tissue damage and occupied wounds into the pressure ulcer topic(Tab. 1).

Etiology

In the development of pressure ulcers, the risk factors, the mechanical boundary conditions and the individual pressure tolerance curve are discussed. Mechanical constraints include the intensity, duration nud the type of mechanical stress (friction, pressure, friction); summarized as internal tissue stressors. Individual tissue sensitivity and tolerance include tissue mechanical properties, tissue and bone geometry, transport and temperature properties, and physiology and repair processes; summarized as tissue damage. The greater the contact pressure and the longer the exposure time to a particular skin area, the greater the risk of pressure ulcers, taking into account individual tissue tolerance [2].

Compression of capillary vessels results in tissue ischemia, accumulation of toxic substances, and tissue loss. Other factors such as shear forces and friction can additionally contribute to tissue damage. The first sign of a superficial pressure ulcer is the fixed redness, which has not completely faded after twelve hours of relief. Failure to adequately relieve this site will result in further tissue damage to the bone. Some pressure ulcers arise from depth and are first recognizable by a hardening or accumulation of fluid at depth [2].

Decubitus has become established as a name in the German-language literature just like decubital ulcers, pressure sores or pressure ulcers. After extensive debate, the term “deep tissue injury” has become accepted in Southeast Asia, Australia, and New Zealand, whereas in Europe the term “pressure ulcer,” “decubitus ulcer,” or “pressure sore” is often used.

Risk factors and risk assessment

High-risk groups include people with advanced age, reduced mobility, after surgery or in intensive care, or with paraplegia [1]. The risk of pressure ulcers is influenced by various factors such as increasing age and the associated skin changes (reduced skin regeneration, skin resistance). Numerous good observational studies have now made it possible to determine the significance of the individual risk factors for the overall risk using multivariate models. The risk factors summarized in Tables 2 and 3 should be noted.

Risk assessment

In order to implement adequate preventive measures and plan interventions at an early stage, the pressure ulcer risk should be assessed regularly. In modern management, the risk factors listed above are combined into a multivariate model. Initial research results show that an integration of algorithms for data-based adjustment of individual risk can be used in clinical practice. With the integration of this knowledge, pressure ulcer prevention appears to be better compared to the use of regularly administered pressure ulcer scales such as the Braden and Norton scales as structured assessments. Until such data-based risk models are widely implemented in everyday life, there is no substitute for the expertise of health professionals in individualized prevention. Regular training for health professionals continues to be useful and contributes to improving quality of care and reducing incidence.

Risk assessment using a validated risk scale is not useful in people with spinal paralysis, because spinal paralysis already represents a high risk and too many preventive measures would rather be initiated [3]. Individualized risk assessment results from regular observation and professional expertise in the bio-psycho-social model of the International Classification of Functioning (ICF) [4]. In an inpatient treatment context, the interdisciplinary team assesses the overall risk from nursing and medical assessment complemented by the therapeutic perspective. In the outpatient context, the patient himself/herself, if necessary supported by caring relatives or outpatient caregivers, should be trained to perform the comprehensive management with prevention, early detection and initiation of further measures. In addition, specialized outpatient services such as ParaHelp or wound outpatient clinics can be consulted. The risk of pressure ulcers increases in the short term [6]:

in case of deterioration of the general condition
for infections and fever
After operations
for immobilization in bed
for autonomic dysregulation
for hypotension.

Measures of pressure ulcer prevention

Regular skin checks include inspection and palpation of the skin, especially the areas at risk (Fig. 1). Depending on the functional and personal abilities of the patients, skin control can be performed by themselves. If necessary, nursing staff or/and caring relatives take over this task, which should be specifically clarified in each case. In patient education, skin control competency is an essential element (Table 4) [5].

Home monitoring intervals are based on the phase of life or the phase of acute treatment or rehabilitation. In the stable outpatient setting, skin should be safely checked in the morning after sleep and in the evening after mobilization. An increased skin control interval is necessary in case of infections, deteriorated general condition, sedation-induced immobilization and skin abnormalities. All observations deviating from the normal skin situation must be documented and adequate nursing interventions initiated.

Complementary measures for prevention

Specialists such as nutritional counselors, occupational or physical therapists, or psychologists may be involved in the implementation of complementary measures [7,8]. Basically, adapted and relieving positioning in bed and in the wheelchair as well as regular relieving in the wheelchair is indicated. Immobilization in bed without repositioning should be avoided. Patients should be mobilized in a wheelchair only as long as their skin can tolerate it. In principle, after a treated pressure ulcer, mobilization to the wheelchair should not exceed six hours and, if possible, a lunch break should be scheduled. If necessary, pressure relief through soft positioning with appropriate mattresses (static or dynamic anti-decubitus mattresses) and adapted positioning material (pillows, positioning wedges, etc.) is required. The seat cushion, sitting position, etc. must be individually adapted to the patient. The positioning intervals must also be adjusted on a dynamic system, because pressure relief by changing the positioning is fundamentally necessary.

Skin care adapted to the patient avoids skin lesions. The skin should also be protected from moisture and irritation. It is important not to leave any foreign objects in the bed or wheelchair. Care should also be taken to avoid friction in clothing and shoes (e.g. seams and folds), shoes can be one to two sizes larger.

The individual nutritional situation should be assessed by structured assessment and nutritional counseling or nutritional therapy should be provided to ensure adequate protein intake, good vitamin and nutrient intake, adjusted caloric and fluid intake [9].

These measures are supported by integrated psychotherapy that targets behavioral modifications for relapse prevention, addresses psychiatric comorbidities, and assists with coping strategies to optimize compliance. In order to achieve good joint therapy for the prevention of pressure ulcers, it is useful to build a partnership of shared understanding from the perspective of experienced stakeholders [14,15]. Patient education that generates understanding is indicated.

Pressure ulcer therapy

Depending on the classification of the pressure ulcer, a conservative therapy concept in an outpatient setting is possible or an operative inpatient treatment concept will be necessary [10]. Due to the complexity, the treatment concept should include the bio-psycho-social aspects according to the ICF model [2].

Conservative measures for pressure ulcers [11,12] include consistent pressure relief using special mattresses and exposure of the affected areas. Causes should be evaluated and eliminated if possible, and risk factors should be minimized preventively. Wound treatment should follow the TIME concept (T = tissue removal, debridement; I = infection control; M = moisture management, promotion of granulation; E = edge protection, epithelialization) (Table 5). If necessary, support materials and aids must be readapted to the individual circumstances. The patient as a contributor is always at the center of effective prevention, so rehabilitation such as learning new self-care techniques, transfer, new movement patterns, and psychological care may be recommended along with other measures. In addition to local therapy with special dressings, various physical measures such as electrostimulation, cold plasma, T Touch massages or water-filtered infrared have a positive effect on wound healing. Since there is no evidence for the superiority of individual measures, they should be used as appropriate.

Because of the high recurrence rates, surgical treatment in a specialized center with appropriate experience and established interdisciplinary treatment teams is recommended [16]. One example is the “Basel Pressure Ulcer Concept”, which integrates the following principles and has been increasingly proven and continuously developed in recent years [2,13]:

Pressure relief
Wound debridement
Wound treatment/wound conditioning
Treatment of general diseases,
Risk factors, nutritional optimization
Defect coverage through plastic surgery
Education/Aftercare/Prophylaxis

Important differential diagnosis

Moisture-related skin lesion and incontinence-associated dermatitis (IAD) is defined as irritant contact dermatitis, the majority of which occurs in patients with fecal and urinary incontinence. Due to the destroyed skin barrier function, inflammation is triggered with weeping skin and superficial wounds. Secondary skin infections are often the result(Table 6). Related terms include diaper dermatitis, moisture lesions, perineal dermatitis, or rash.

Risk factors include frequent episodes of fecal and urinary incontinence, use of occlusive incontinence products, poor skin condition (skin defense is compromised, aging skin, influence of steroids), and elevated body temperature.

For the treatment of IAD, moisture management is particularly important in addition to the treatment principles described above for pressure ulcers.

Take-Home Messages

Pressure sores occur in typical locations over bony prominences or due to pressure from medical devices. The following are identified as vulnerable groups: seriously ill people, people with paraplegia, in palliative settings, with obesity, premature infants, elderly people with chronically impaired functioning, and during surgery.
The depth of the pressure ulcer according to the international classification EPUAP leads to different treatment concepts (conservative or surgical).
Pressure relief as the most important first measure requires special planning in the outpatient setting.
Wound healing and local wound care should be regularly monitored by specialized professionals, as it is a complicated wound healing process.
Risk factors in the bio-psycho-social understanding should be imperatively analyzed in a structured way and treated in an individualized way.

Literature:

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