eMedicine Specialties > Plastic Surgery > Pressure Ulcers

Pressure Ulcers, Nonsurgical Treatment and Principles: Follow-up

Author: Christian N Kirman, MD, Resident Physician, Department of Plastic and Reconstructive Surgery, Wake Forest University Baptist Medical Center
Coauthor(s): Joseph A Molnar, MD, PhD, FACS, Associate Director of Burn Unit, Associate Professor, Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine
Contributor Information and Disclosures

Updated: Jul 28, 2009

Follow-up

Further Inpatient Care

  • Patients may benefit from transfer to a subacute or rehabilitation facility following wound closure. This allows for ongoing education, observation, and rehabilitative therapies prior to returning to their usual place of residence.

Further Outpatient Care

  • Patients also may benefit from visits from a home health care organization once they return home. This may ease the transition and ensure that pressure avoidance strategies are adapted to the home and continued over the long term.

Inpatient & Outpatient Medications

  • Spasticity should be alleviated and adequate nutrition maintained in the outpatient setting to prevent recurrence or new ulceration.

Deterrence/Prevention

  • The ultimate success or failure of pressure sore healing only begins with wound closure. Prevention of recurrence and new ulceration then becomes the goal. Long periods of uninterrupted pressure should still be avoided through frequent repositioning. Pressure dispersion through the application of specialized support surfaces on beds and wheelchairs should be extended through the wound healing period and into the outpatient setting if available and tolerated by the patient. These products are an adjunct to and not a replacement for alternating weight-bearing surfaces.
  • Skin care should be performed daily. This involves a careful inspection of all skin surfaces to identify areas of impending breakdown prior to their occurrence. An often overlooked but necessary detail is to remove compression stockings and inspect the heels. Skin should be washed with soap and water and completely dried at regular intervals and immediately upon soiling. Moisture should not accumulate on the skin or in clothing or bedding, nor should one allow the skin to become overly dry and scaly. Skin moisturizers are useful to maintain the appropriate level of moisture at the skin surface.

Complications

  • Complications fall into 1 of 2 categories: complications of chronic ulceration and complications of ulcer reconstruction.
  • Although uncommon, grossly infected pressure sores leading to bacteremia, sepsis, myonecrosis, necrotizing fasciitis, or gangrene represent the most serious complication. Another serious complication of chronic ulceration is malignant degeneration, or Marjolin ulceration. Initially described by Marjolin in 1828 as a cancer arising in burn scars, malignant degeneration has been reported in chronic pressure sores. These malignancies are typically aggressive squamous cell carcinomas with a high likelihood of nodal metastasis at the time of diagnosis. Any longstanding nonhealing wound should alert the examiner to the need to perform a biopsy.
  • Complications as a result of reconstructive surgery are unfortunately considerable. These include hematoma, seroma, wound dehiscence, wound infection, flap necrosis, and recurrence.

Prognosis

  • Even with the development and implementation of new pressure-relieving surfaces and an increase in awareness among health care providers, no studies have demonstrated a decrease in incidence or prevalence of pressure ulceration during the last 3 decades. More distressing, recurrence rates as high as 90% are reported in the literature.

Patient Education

  • Patients and their support system must realize that it is their responsibility to avoid recurrent and new ulceration and that this is a lifelong process.17  Education on the proper avoidance of pressure should begin in the hospital and continue into the home.

Miscellaneous

Medicolegal Pitfalls

  • The ethics of pressure sore treatment should be carefully considered. The aggressive treatment of pressure ulceration is outlined in this article and others. This treatment is certainly indicated for a subset of patients who experience pressure ulceration: the acutely hospitalized patient with a recoverable illness.
  • For others, such as patients who are chronically or terminally ill with longstanding or recurrent ulceration, aggressive treatment may not be in the best interest of the patient. In these instances, the wishes of the patient or the patient's family should be weighed carefully. The presence of advanced directives, a living will, or a person recognized as having power of attorney should be considered. In many instances, conservative medical care and maintaining patient comfort should be the goals rather than the institution of major invasive procedures.
  • The Centers for Medicare & Medicaid Services' definition of avoidable and unavoidable pressure ulcers in long-term care settings and the recent change in prospective payment for facility-acquired pressure ulcers in hospitals has prompted the Wound, Ostomy and Continence Nurses Society (WOCN) to release a position statement on the topic of avoidable and unavoidable pressure ulcers based on the most current literature. According to this statement, unavoidable pressure ulcers develop under clinical circumstances after interventions have been implemented based upon the patient's clinical condition and pressure ulcer risk factors that are consistent with a patient's needs, goals, and recognized standards of practice.18 The full position statement is available here.

Special Concerns

  • Promising research in the field of growth factors and wound healing has shed light on the complex interactions that take place at the wound surface and in the affected organism as a whole. This has led to the introduction of becaplermin (Regranex), recombinant human platelet-derived growth factor. This topical agent has been approved by the FDA for the treatment of lower extremity diabetic neuropathic ulcers that extend into the subcutaneous tissue or beyond. Studies are underway to possibly expand the approved indications for this drug to include other wounds. Other growth factors are being evaluated for use in clinical settings as well. This expanding field surely will contribute further application of basic science to clinical wound healing with improvement of our understanding and patient care.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Don R Revis Jr, MD, to the development and writing of this article.



More on Pressure Ulcers, Nonsurgical Treatment and Principles

Overview: Pressure Ulcers, Nonsurgical Treatment and Principles
Differential Diagnoses & Workup: Pressure Ulcers, Nonsurgical Treatment and Principles
Treatment & Medication: Pressure Ulcers, Nonsurgical Treatment and Principles
Follow-up: Pressure Ulcers, Nonsurgical Treatment and Principles
Multimedia: Pressure Ulcers, Nonsurgical Treatment and Principles
References
[ CLOSE WINDOW ]

References

  1. Gallagher SM. Outcomes in clinical practice: pressure ulcer prevalence and incidence studies. Ostomy Wound Manage. Jan-Feb 1997;43(1):28-32, 34-5, 38; quiz 39-40. [Medline].

  2. Fogerty MD, Abumrad NN, Nanney L, Arbogast PG, Poulose B, Barbul A. Risk factors for pressure ulcers in acute care hospitals. Wound Repair Regen. Jan-Feb 2008;16(1):11-8. [Medline].

  3. Whittington KT, Briones R. National Prevalence and Incidence Study: 6-year sequential acute care data. Adv Skin Wound Care. Nov-Dec 2004;17(9):490-4. [Medline].

  4. Paget J. Clinical lecture on bed sores. Students J Hosp Gaz. 1873;1:144-7.

  5. Reuler JB, Cooney TG. The pressure sore: pathophysiology and principles of management. Ann Intern Med. May 1981;94(5):661-6. [Medline].

  6. Amlung SR, Miller WL, Bosley LM. The 1999 National Pressure Ulcer Prevalence Survey: a benchmarking approach. Adv Skin Wound Care. Nov-Dec 2001;14(6):297-301. [Medline].

  7. Kenkel JM. Pressure Sores (overview). In: Kenkel JM. Selected Read Plast Surg. Vol 8, No 39. Texas: Baylor University Medical Center; 1998:1-29.

  8. Klitzman B, Kalinowski C, Glasofer SL, Rugani L. Pressure ulcers and pressure relief surfaces. Clin Plast Surg. Jul 1998;25(3):443-50. [Medline].

  9. Leblebici B, Turhan N, Adam M, Akman MN. Clinical and epidemiologic evaluation of pressure ulcers in patients at a university hospital in Turkey. J Wound Ostomy Continence Nurs. Jul-Aug 2007;34(4):407-11. [Medline].

  10. Dinsdale SM. Decubitus ulcers: role of pressure and friction in causation. Arch Phys Med Rehabil. Apr 1974;55(4):147-52. [Medline].

  11. Barbenel JC, Jordan MM, Nicol SM, Clark MO. Incidence of pressure-sores in the Greater Glasgow Health Board area. Lancet. Sep 10 1977;2(8037):548-50. [Medline].

  12. Black J, Baharestani M, Cuddigan J, Dorner B, Edsberg L, Langemo D, et al. National Pressure Ulcer Advisory Panel's updated pressure ulcer staging system. Dermatol Nurs. Aug 2007;19(4):343-9; quiz 350. [Medline].

  13. Schols JM, Heyman H, Meijer EP. Nutritional support in the treatment and prevention of pressure ulcers: An overview of studies with an arginine enriched Oral Nutritional Supplement. J Tissue Viability. May 2009;[Medline].

  14. [Best Evidence] Cereda E, Gini A, Pedrolli C, Vanotti A. Disease-specific, versus standard, nutritional support for the treatment of pressure ulcers in institutionalized older adults: a randomized controlled trial. J Am Geriatr Soc. Aug 2009;57(8):1395-402. [Medline].

  15. Woolsey RM, McGarry JD. The cause, prevention, and treatment of pressure sores. Neurol Clin. Aug 1991;9(3):797-808. [Medline].

  16. Heyneman A, Vanderwee K, Grypdonck M, Defloor T. Effectiveness of Two Cushions in the Prevention of Heel Pressure Ulcers. Worldviews Evid Based Nurs. May 2009;[Medline].

  17. Relander M, Palmer B. Recurrence of surgically treated pressure sores. Scand J Plast Reconstr Surg Hand Surg. 1988;22(1):89-92. [Medline].

  18. Wound, Ostomy and Continence Nurses Society Position Statement on Avoidable Versus Unavoidable Pressure Ulcers. J Wound Ostomy Continence Nurs. Apr 2009;[Medline]. [Full Text].

  19. Bergstrom N, Horn SD, Smout RJ, Bender SA, Ferguson ML, Taler G, et al. The National Pressure Ulcer Long-Term Care Study: outcomes of pressure ulcer treatments in long-term care. J Am Geriatr Soc. Oct 2005;53(10):1721-9. [Medline].

  20. Clark M, Hiskett G, Russell L. Evidence-based practice and support surfaces: are we throwing the baby out with the bath water?. J Wound Care. Nov 2005;14(10):455-8. [Medline].

  21. Conway H, Griffith BH. Plastic surgery for closure of decubitus ulcers in patients with paraplegia; based on experience with 1,000 cases. Am J Surg. Jun 1956;91(6):946-75. [Medline].

  22. Crenshaw RP, Vistnes LM. A decade of pressure sore research: 1977-1987. J Rehabil Res Dev. Winter 1989;26(1):63-74. [Medline].

  23. Dansereau JG, Conway H. Closure of decubiti in paraplegics. Report of 2000 cases.. Plast Reconstr Surg. May 1964;33:474-80. [Medline].

  24. De Laat EH, Schoonhoven L, Pickkers P, Verbeek AL, Van Achterberg T. Implementation of a new policy results in a decrease of pressure ulcer frequency. Int J Qual Health Care. Apr 2006;18(2):107-12. [Medline].

  25. El-Toraei I, Chung B. The management of pressure sores. J Dermatol Surg Oncol. Sep-Oct 1977;3(5):507-11. [Medline].

  26. Inman KJ, Sibbald WJ, Rutledge FS, Clark BJ. Clinical utility and cost-effectiveness of an air suspension bed in the prevention of pressure ulcers. JAMA. Mar 3 1993;269(9):1139-43. [Medline].

  27. Ladin DA. Understanding dressings. Clin Plast Surg. Jul 1998;25(3):433-41. [Medline].

  28. Lahmann NA, Halfens RJ, Dassen T. Pressure ulcers in German nursing homes and acute care hospitals: prevalence, frequency, and ulcer characteristics. Ostomy Wound Manage. Feb 2006;52(2):20-33. [Medline].

  29. Maklebust J. An update on horizontal patient support surfaces. Ostomy Wound Manage. Jan 1999;45(1A Suppl):70S-77S; quiz 78S-79S. [Medline].

  30. Mustoe T, Upton J, Marcellino V, Tun CJ, Rossier AB, Hachend HJ. Carcinoma in chronic pressure sores: a fulminant disease process. Plast Reconstr Surg. Jan 1986;77(1):116-21. [Medline].

  31. Mustoe TA, O'Shaughnessy K, Kloeters O. Chronic wound pathogenesis and current treatment strategies: a unifying hypothesis. Plast Reconstr Surg. Jun 2006;117(7 Suppl):35S-41S. [Medline].

  32. Nola GT, Vistnes LM. Differential response of skin and muscle in the experimental production of pressure sores. Plast Reconstr Surg. Nov 1980;66(5):728-33. [Medline].

  33. Piascik P. Use of Regranex gel for diabetic foot ulcers. J Am Pharm Assoc (Wash). Sep-Oct 1998;38(5):628-30. [Medline].

  34. Redfern SJ, Jeneid PA, Gillingham ME, Lunn HF. Local pressures with ten types of patient-support system. Lancet. Aug 11 1973;2(7824):277-80. [Medline].

  35. Rogers J, Wilson LF. Preventing recurrent tissue breakdowns after "pressure sore" closures. Plast Reconstr Surg. Oct 1975;56(4):419-22. [Medline].

  36. Siegler EL, Lavizzo-Mourey R. Management of stage III pressure ulcers in moderately demented nursing home residents. J Gen Intern Med. Nov-Dec 1991;6(6):507-13. [Medline].

  37. Staas WE Jr, LaMantia JG. Decubitus ulcers and rehabilitation medicine. Int J Dermatol. Oct 1982;21(8):437-44. [Medline].

  38. Stal S, Serure A, Donovan W, Spira M. The perioperative management of the patient with pressure sores. Ann Plast Surg. Oct 1983;11(4):347-56. [Medline].

  39. Thomas, DR. Pressure Ulcers. In: CK, Cassel. Geriatric Medicine. New York: Springer; 1997.

  40. Thompson RJ. Pathological changes in mummies. Proc R Soc Med. 1961;54:409.

  41. Wagner D, Fox M, Ellis E. Developing a successful interdisciplinary seating program. Ostomy Wound Manage. Jan-Feb 1994;40(1):32-4, 36-8, 40-1. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

decubitus ulcers, pressure sores, ulcerations, pressure ulcers, surgical and nonsurgical treatment, decubitus, ischial tuberosity ulcer, ischemia, tissue necrosis, capillary filling pressure, shear forces, friction sores, maceration, microcirculatory occlusion, tissue anoxia, Shea classification, National Pressure Ulcer Advisory Panel, pressure reduction, tissue perfusion, sacrum ulcer, operative debridement, skeletal muscle relaxants, repositioning

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Christian N Kirman, MD, Resident Physician, Department of Plastic and Reconstructive Surgery, Wake Forest University Baptist Medical Center
Christian N Kirman, MD is a member of the following medical societies: North Carolina Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Joseph A Molnar, MD, PhD, FACS, Associate Director of Burn Unit, Associate Professor, Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine
Joseph A Molnar, MD, PhD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Plastic Surgeons, North Carolina Medical Society, Peripheral Nerve Society, and Wound Healing Society
Disclosure: KCI, Inc.  Honoraria Speaking and teaching; Integra Life Sciences Honoraria Speaking and teaching; Clincal Cell Culture Grant/research funds Co-investigator; KCI, Inc Wake Forest University receives royalties Other

Medical Editor

Albert E Cram, MD, FACS, Professor Emeritus, Departments of Surgery, Otolaryngology Head & Neck Surgery and Orthopedic Surgery, University of Iowa College of Medicine; Consulting Staff, Iowa City Plastic Surgery
Albert E Cram, MD, FACS is a member of the following medical societies: American Association of Tissue Banks, American Burn Association, American College of Surgeons, American Heart Association, American Society for Aesthetic Plastic Surgery, and American Society of Plastic Surgeons
Disclosure: ethicon Grant/research funds Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Wayne Stadelmann, MD, Stadelmann Plastic Surgery, PC
Wayne Stadelmann, MD is a member of the following medical societies: Alpha Omega Alpha, New Hampshire Medical Society, Northeastern Society of Plastic Surgeons, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Lars M Vistnes, MD, FRCSC, FACS, Professor of Surgery, Emeritus, Stanford University Medical Center
Lars M Vistnes, MD, FRCSC, FACS is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.