Prevention Using specialized support surfaces

Using specialized support surfaces (including mattresses, beds, and cushions), patient repositioning, optimizing nutritional status, and moisturizing sacral skin are strategies that have been shown to reduce pressure ulcers. For moderate- to high-risk patients, mattresses or overlays that reduce tissue pressure below a standard mattress appear to be superior to standard mattresses. The literature comparing specific products is sparse and inconclusive.
? Evaluation
Evaluation of pressure ulcers should include patient’s risk factors and goals of care, wound stage, size, depth, presence or absence of exudate, type of exudate present, appearance of the wound bed, and whether there appears to be surrounding infection, sinus tracking, or cellulitis. In poorly healing or atypical pressure ulcers, biopsy should be performed to rule out malignancy or other less common lesions such as pyoderma gangrenosum.
? Treatment
Treatment is aimed toward removing necrotic debris and maintaining a moist wound bed that will promote healing and formation of granulation tissue. The type of dressing that is recommended depends on the location and depth of

Table 4-5. Treatment of pressure ulcers.
Ulcer Type
Dressing Type and Considerations
Stage I and suspected deep tissue injury
Polyurethane film Hydrocolloid wafer Semipermeable foam dressing
Stage II
Hydrocolloid wafers Semipermeable foam dressing Polyurethane film
Stage III/IV
For highly exudative wounds, use highly absorptive dressing or packing, such as calcium alginate Wounds with necrotic debris must be debrided Debridement can be autolytic, mechanical (wet to moist), or surgical Shallow, clean wounds can be dressed with hydrocolloid wafers, semipermeable foam, or polyurethane film Deep wounds can be packed with gauze; if the wound is deep and highly exudative, an absorptive packing should be used
Heel ulcer
Do not remove eschar on heel ulcers because it can help promote healing (eschar in other locations should be debrided)
Debride before deciding on further therapy

the wound, whether necrotic tissue or dead space is present, and the amount of exudate (Table 4-5). Pressure- reducing devices (eg, air-fluid beds and low air loss beds) are associated with improved healing rates. Although poor nutritional status is a risk factor for the development of pressure ulcers, the results of trials of nutritional supplementation in the treatment of pressure ulcers have been disappointing.