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HARTMANN medicaledition – Phase-specific wound management of decubitus ulcer
PAUL HARTMANN AG
Unit P2 Parklands
Heywood Distribution Park
Pilsworth Road
Heywood, Lancs OL10 2TT
United Kingdom
Phase-specific
wound management
of decubitus ulcer
B34 (0106) 086 XXX/X
PAUL HARTMANN AG
P.O. Box 14 20
D-89504 Heidenheim
Germany
Wound Management
Published by
PAUL HARTMANN AG
D-89522 Heidenheim
http://www.hartmann.info
Concept, design, editing and
production:
CMC Medical Information
D-89522 Heidenheim
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
April 2006
ISBN 3-929870-44-4
Translated from the German
edition (ISBN 3-929870-41-X)
Paper bleached by a chlorine-free
process
Table of contents
Preface
5
Development of decubitus – a multifactorial process
– Common sites of decubitus ulcer formation
– Decubitus hazards and risk factors
– Classification and degrees of severity of decubitus
6
9
10
18
Management of decubitus – general principles
– Relief of pressure as the basis of all treatment
– Phase-specific moist wound treatment
– Identification and treatment of factors interfering with wound healing
20
27
30
39
Hydroactive wound dressings for phase-specific, moist wound treatment
– TenderWet – wound pad with superabsorber
– Sorbalgon – calcium alginate dressings with excellent conformability
– PermaFoam – hydroactive foam dressing
– Hydrocoll – absorbent hydrocolloid dressing
– Hydrosorb – transparent hydrogel dressing
46
48
53
57
60
63
Nursing activities for decubitus prophylaxis
70
Supplementary aids for treatment and nursing care
73
Glossary and list of key terms
77
References and list of illustrations
79
[2.3]
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 clinical studies to elaborate guidelines for practicable prophylactic and therapeutic activities and establish them as
standard practices.
Despite these efforts, pressure ulcer with an annual incidence of 150,000 cases in Stages III and IV still remains a
major problem for a number of reasons. The growing number 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 knowledge relating to the pathogenesis of pressure ulcer and
sets out successful therapeutic principles which, if applied
consistently, promise good prospects of a cure. It should
nevertheless be emphasized that the management of decubitus 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.
[4.5]
Development of decubitus –
a multifactorial process
Immobility and the resulting abnormally long period of
exposure to pressure is without doubt the central causal
factor in the pathogenesis of pressure ulcer.
However, a large number of other risk factors specific to
individual patients also contribute to the development of
pressure sore, which makes the process highly complex and
difficult to define. Nevertheless, a program of treatment and
nursing care will attempt to address the patient’s needs on
a holistic basis and not merely treat the pressure ulcer as an
isolated phenomenon.
A decubitus ulcer is defined as damage to the skin resulting 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 counterpressure on the area of skin bearing upon it. The degree of
counterpressure varies depending on the hardness of the
supporting 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 higher 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 interrupt 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, anesthesia, severe dementia and/or if they are no longer strong
enough to move unaided in response to pain, the compression 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 regenDevelopment of decubitus [6.7]
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.
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
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, persisting
pressure 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 average tolerance range of the skin is subject to considerable
variations which are determined by the individual patient’s
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. The
risk 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.
Examples of “classical” sites of
predilection for pressure sores:
1) Sacral region
2) Heel
3) Trochanter
4) Lateral malleolus
1
2
3
4
Development of decubitus [8.9]
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 and
slight 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 is
causally related to the duration of pressure exposure. The
hazard increases with the patient’s 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
䢇 in dorsal position: sacral bone and coccyx, heels and Achilles tendons,
elbows, shoulder blades and occipital bone
䢇 in abdominal position: frontal bone, elbows, breastbone and costal
arches, iliac crest, kneecaps and tips of the toes
䢇 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
䢇 in sitting position: ischial tuberosity, occipital bone, spine and heels;
if poorly supported, there is also a potential hazard from shear forces
Development of decubitus [10.11]
Total immobility: If spontaneous movements are no
longer possible, the patient is absolutely at risk. Total
immobility is seen, for example, in unconscious, anesthetised or completely paralysed patients. The patient’s
age is irrelevant.
Relative immobility: A high hazard potential is present
because spontaneous movements are more or less restricted, for example due to sedation, fractures, severe
pain, 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 illnesses 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 skin’s tolerance of hypoxia also decreases.
Blood perfusion can be impaired by a multiplicity of factors, 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 secondary 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 skin’s resistance to
pressure. Incontinence is thus another risk factor affecting
especially elderly, bedbound patients. It is, however, incorrect to assume that incontinence alone can cause a pressure sore. The causal factor in pressure ulcer is pressure,
and incontinence is a contributory factor.
Debilitated general condition: Chronic or severe illnesses, malignant processes, infections, malnutrition characterized by protein, vitamin and zinc deficiency, anemia, exsiccosis, cachexia etc. also increase the risk of pressure sore.
Many of the diseases greatly restrict the patient’s mobility/
motility and impair the skin’s metabolism.
Development of decubitus [12.13]
Physiological aging of the skin: Independently of coexisting 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 skin’s connective tissue loses elasticity. As
a result, the skin’s ability to tolerate mechanical loading
decreases, and exposure to pressure can lead to the formation 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 patient’s skin and
damages them. However, there are also secondary, operation-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 themselves include existing skin damage, e.g. due to confinement 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 repositioning (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 support, patient hypothermia, incorrect use of disinfectants
(especially in the coccyx region, which can also lead to
excessive cooling of the skin because iodine- and alcoholcontaining 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
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
■
Secondary risk factors that especially reduce tissue tolerance
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
■
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 skin’s 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)
Development of decubitus [14.15]
Assessment of hazard from pressure ulcer
Estimating each patient’s 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 patient’s 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 assessment 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 a little
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
patient’s status, a risk of pressure ulcer is present at a score of
25 points and less. Prophylactic measures must be planned and
implemented immediately.
Development of decubitus [16.17]
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 classifications are used, such as Daniel’s classification into five
degrees of severity, which is used particularly in the surgical field, or the most commonly used classification into
four degrees of severity developed by the “National Pressure 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 reddening 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 affected. Clinically, the pressure ulcer looks like an open sore
with or without undermining of the surrounding tissue.
Epidermis
Stage I
Dermis
Classification of the severity of
pressure ulcer is based on which
tissue layers have already been
destroyed by exposure to pressure.
Stage II
Subcutis
Stage III
Muscles,
Tendons,
Bones
Stage IV
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 intraoperative exposure to pressure. An ulcer covered with scab
and 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.
Development of decubitus [18.19]
Management of decubitus –
general principles
A decubitus ulcer not infrequently takes many months to
heal and in elderly persons often presents a challenge that
remains unmastered. Not least, this may be because of the
extreme difficulty in translating the complexity of pressure
ulcer causation and chronic wound healing into easily
understandable, standardized therapeutic concepts.
Medicine and nursing are therefore called upon to develop
a treatment which as far as possible takes into account the
individual patient’s 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 carefully 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 patient’s 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 patient’s general
condition and nutritional status and to provide adequate 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 the
drawing 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.
Ringer’s solution) using a syringe.
Management of decubitus [20.21]
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, in
association 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 patient’s status
The assessment of the patient should include the general
condition, possible complications and concomitant diseases, the nutritional status, the severity of any pain, but
also a careful inventory of the psychosocial situation.
General physical condition: Wound healing is not merely a local process, but is linked to processes in the entire
body on many levels; consequently, an improvement in the
patient’s general condition can have a major influence on
wound healing.
Initial assessment of overall situation
Course of treatment
for decubitus
■ Localization of the ulcer, severity, general
condition of the wound
■ Evaluation of the patient’s status, compliance
Treatment
Causal therapy
■ Complete relief of pressure to restore the blood
supply throughout the treatment period until the
ulcer has healed
Local ulcer therapy
■ Adequate surgical debridement
■ Infection control, when appropriate
■ Moist dressing treatment for further wound
cleansing, conditioning and epithelisation
■ Plastic surgery techniques as appropriate
Adjuvant therapies
■
■
■
■
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
Ulcer healing?
yes
no
Course of treatment for decubitus ulcer supervision
and continuation of therapy according to treatment
schedule
Careful monitoring of activities (especially whether
pressure relief is adequate)
Management of decubitus [22.23]
Depending on the patient’s 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
patient’s 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 endocarditis, 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 pressure 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
patient’s wishes, by providing adequate dietary intake
with 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 kilogram 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:
❏ Stage II:
❏ Stage III:
❏ Stage IV:
skin reddening with intact epidermis
superficial ulcer, partial loss of epidermis as far as dermis
deep, open ulcer, damage to all skin layers as far as the fasciae
extensive tissue necroses, damage to all skin layers including
muscles, tendons and bones
Yes
Pocket formation
Undermining
Necrotic tissue:
Exudate:
Granulation:
No
closed black necrotic cap
scab
slimy layers
serous-bloody
purulent
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
Management of decubitus [24.25]
and a high-dose multivitamin preparation. If normal
dietary intake is insufficient or impossible, a fully balanced
liquid drinking diet or a parenteral diet should be 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 decubitus patient is being treated in hospital, in a nursing facility 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 situation, however, sometimes presents greatly differing baseline conditions in terms of the patient’s ability to fully
understand the therapeutic requirements and “cooperate”
with the treatment. The aim of the psychosocial assessment 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 psychosocial situation is thus of major importance especially
in domiciliary care context. Aspects to be evaluated
include the patient’s 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 nursing 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 treatment
Decubitus ulcers develop as the result of unrelieved exposure 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 treatment 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 immediate 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 pressure 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.
Management of decubitus [26.27]
The 90 degree oblique positioning should no longer be
used, either for prophylaxis or for treatment, because most
of the body’s weight then bears on the trochanter. Even
before beginning any treatment, therefore, the type of
positioning suitable for each patient should be established, and should lead to the establishment of binding
guidelines for all those involved in the treatment and
nursing of the patient.
The correct positioning of the
patient depends on the localization of the decubitus ulcer.
The basic positioning variants
shown here are also suitable
for prophylaxis.
The different positioning techniques require the combined
use of static and dynamic aids. Static aids, such as positioning 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 positioning individual parts of the body and exposing other
parts to pressure.
The patient must also lie securely and without the risk of
slipping on the positioning aids. With inexpert positioning,
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, right
30 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
the unfavourable weight distribution creates shear forces.
For larger decubitus ulcers, patients with multiple risk factors 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 to
position patients correctly according to their requirements.
It is by no means sufficient simply to slide a cushion somewhere 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 influencing the patient’s 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.
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 shoulder blades, the bony profile of the
spine, the sacrum, coccyx and
heels are positioned almost completely free.
For the 30 degree oblique positioning (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 underneath the patient’s back.
The knees can additionally be
padded with a cushion.
Management of decubitus [28.29]
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 controlling 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.
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
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21
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 microorganisms 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 body’s 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, necroses
prevent healing since they maintain the chronicity of the
wound.
The more effective the cleansing
of the ulcer, the better the quality
of the subsequent granulation tissue will be. Hydroactive wound
dressings perform valuable service
in this respect.
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 wound
debridement are activities reserved for the physician in
both the inpatient and outpatient settings. The physician’s
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.
Management of decubitus [30.31]
The situation, all too common in clinical practice, of someone “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 operating 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 debridement
means softening and detaching necrotic material and fibrinous 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 promotes 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 decubitus
ulcer.
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 and
effective as surgical debridement and cleansing will take a
longer time, a fact which demands a patient and conscientious 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 Ringer’s
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.
Management of decubitus [32.33]
Infected decubitus with pus formation; if bacterial toxins are
transferred through the lymph
tracts and blood stream to other
organs, bacteremia or sepsis may
result.
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 periwound 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 culture 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 sometimes considerable inhibitory effects on wound healing and
the toxic properties of some antiseptic substances. If the
ulcer exhibits clinically overt infection and if antiseptics are
to be used for a short period, when choosing the antiseptic 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. It
involves the risk of resistance development and a change
of the pathogens as well as a greater risk of allergy development than is the case with antiseptics. Furthermore,
it is difficult to achieve a sufficient active agent concentration deep inside the wound and to estimate the inhibition
of wound healing processes.
In patients with severe infections, the systemic administration of antibiotics is indicated, and a microbial determination 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 granulation tissue, must be produced to fill the defect.
Getting through this phase and supporting the wound in
the best possible manner often presents considerable difficulties 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 period so that blood supply to the wound area remains intact
and is not impaired by renewed exposure to pressure.
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 dressing in this phase.
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 disinfected, particular care should be exercised in the areas
around the granulation tissue.
Management of decubitus [34.35]
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 prolonged 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 bacteriaproof 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 demonstrating 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 the
patient. 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 therapeutic 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 maintained.
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 %.
Increasing wound contraction and
epithelisation from the wound
margin due to cell mitosis and
migration of epithelial cells complete the wound healing process.
A moist wound environment is
also required in this phase.
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 no
further epithelisation can then take place from the wound
margins, the wound margins should be refreshed by trimming 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 patient’s
already debilitated general condition. In addition, conservative treatment is always protracted, which is not only
unsatisfactory for the patient and therapist but also places
an 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-effectiveness. Whenever possible, therefore, not only younger
patients but, increasingly, elderly patients with more
severe decubitus ulcers should benefit from this procedure.
Management of decubitus [36.37]
Defect coverage by plastic surgery can only be fully successful if the patient is optimally prepared for the procedure. Basically, six principles should be followed, and are
always implemented in the same order: Pressure relief,
debridement, wound conditioning, treatment of risk factors, 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 treatment 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
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 transposed into the defect, gluteus
maximus fully intact, problem-free
closure of graft site. Flap completely tension-free in the defect
after closure of graft site.
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 inputintensive 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 paramount 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 chronological 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 for
such 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.
Management of decubitus [38.39]
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 treatment
䊳 Use of antibiotics
䊳 Removing of devitalized tissue
(debridement)
䊳 Reduction of fever
䊳 Provision of quality nutrition
䊳
Search for causes of catabolism
Search for cause of
malnutrition (multifactorial):
e.g. gastric ulcer, depression,
zinc deficiency
䊳 Causal therapy of malnutrition
䊳 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
Diseases
■ Depression, social isolation
■ Anemia
■ Dehydration
■ Diabetes mellitus
■ Immune weakness
■ Heart failure
■ Renal failure
■ Diseases of the gastrointestinal tract
■ Paralysis
■ Immobility
■ Nicotine abuse
䊳
䊳
Medications
■ Corticosteroids
■ Sedative medications
■ Cytostatics
■ Immunosuppressive agents
■ Toxic topical therapeutic
agents, e.g. hydrogen peroxide
Local interfering factors
(local findings)
䊳 Always
treat diseases
optimally, since diseases lead
to catabolism
䊳 Depression: SSRI, care
䊳 Hemoglobin > 11 g / dl
䊳 Drinking volume:
> 20 ml / kg body weight
䊳 Diabetes mellitus: optimal
glucose levels
䊳 Heart failure, e.g. no leg
edema!
䊳 White blood count > 2000
(abs.)
䊳 Serum zinc > 12 mmol / L
䊳 Mobilise
Always check topical therapeutics and medications for negative effects on wound healing
䊳 Sedative medications immobilise and impede pressure
relief
䊳
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
䊳
䊳
Optimize pressure relief
Use only thin, moist dressings
Debridement
Optimize pressure relief
䊳 Use only thin, moist dressings
䊳 Systemic antibiotics if infectious parameters elevated
䊳
䊳
Debridement
Keep permanently moist
䊳 Dressing change 4 x daily
䊳
䊳
Wound irrigation with Ringer’s
solution
䊳 Keep permanently moist with
suitable hydroactive wound
dressings, e.g. hydrocolloid
dressings
䊳
䊳
Check wound preparations for
topical tissue toxicity
Management of decubitus [40.41]
1) Trochanter decubitus with local
infection with clearly visible reddening 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 reddening close to the ulcer edge
4) Whitish, hyperkeratotic lesions
(incipient callus formation) are a
typical sign of insufficient pressure 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 successively addressing factors that delay healing, however, can
provide 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 preventing 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 difficult 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 deficiency, the patient’s mental state, depression, social isolation, fever etc. The elimination of interfering factors thus
represents an attempt to restore the physiological wound
conditions and address the patient’s 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 of
treatment.
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.
Management of decubitus [42.43]
Wound documentation is also an effective means of reliably 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 conflicting 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 thus indispensable for assuring the standards 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 meeting, are not a suitable means of providing the legally
required 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 imprecise.
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 documentation, however, certain legal aspects must be taken into
account, relating mainly to the patient’s 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 photographic records taken at different times.
Camera and photographic technique are to be chosen such that
the images are durable and do
not fade and retain their evidential
power even after years if necessary. This is assured by the use of
digital cameras, which also incur
no costs for developing negatives.
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 be
sharply imaged; a flash may be
used if necessary. The background
should be as “neutral” 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 photographed object are not parallel,
the picture will be distorted
and will not reproduce the size
conditions exactly.
Management of decubitus [44.45]
Hydroactive wound dressings
for phase-specific,
moist wound treatment
Moist wound treatment is today the standard approach for
all secondary healing wounds with tissue formation. It is
particularly successful in the management of chronic problem
wounds. Practitioners have at their disposal a range of
hydroactive wound dressings for moist therapy which cover
the entire spectrum of therapeutic requirements in the form
of 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 treatment 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 consequently 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 of
the 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 such
as gel forming calcium alginate
dressings (below).
Hydroactive wound dressings [46.47]
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.
1
2
3
The principle of action of
TenderWet
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 granulation phase. This high efficiency is attributable to a special
principle of action which allows continuous “rinsing” of
the wound.
TenderWet is a multilayered dressing pad containing superabsorbent polyacrylate (SAP) as the central component
of its absorbent core. The non-medicated superabsorber is
activated before use with an appropriate volume of
Ringer’s solution which is then supplied continuously to
the wound over a period of hours. The constant delivery
of Ringer’s 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 – Ringer’s solution is delivered and
proteins are absorbed – functions because the superabsorber has a greater affinity for the protein-containing
wound exudate than for the sodium-containing Ringer’s
solution (2) and so the wound exudate displaces the
solution from the wound pad.
As soon as the factors inhibiting wound healing are
removed, i.e. the wound has been cleansed of necrotic
tissue, detritus and coatings, the conditions necessary for
the buildup of granulation tissue are present: proliferative
cells can migrate into the wound area and capillary
TenderWet 24 and TenderWet are
available in a range of sizes and
shapes to allow good adaptation
to different wound conditions.
TenderWet 24 and TenderWet are
activated with Ringer’s solution or
TenderWet solution directly in the
half-opened, sterile peel pack
(right).
ingrowth is possible (3). The moisture and the electrolytes
contained in the Ringer’s solution, such as sodium, potassium 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 cleansing 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 available in round and rectangular shapes to meet differing
application requirements.
The classical TenderWet maintains its absorbent-rinsing
action for about 12 hours. Dressing changes should
therefore be carried out every 12 hours. The frequency of
dressing change, however, ultimately depends on the
amount of exudate produced by the wound. How much
Ringer’s solution is required to activate the dressing
Hydroactive wound dressings [48.49]
Treatment of a pressure sore on
the heel with TenderWet (Case
study by Antje Wagner, LeinfeldenEchterdingen): 84-year-old female
patient, coronary heart disease,
arterial occlusive disease, increasing dementia; decubitus on the
left heel. Start of TenderWet treatment on 23 April 99, the necrosis
of the heel extended almost as far
as the bone (Fig. 1). By 7 May the
necrotic tissue on the heel had
begun to scale away (Fig. 2).
Treatment with TenderWet was
continued, and on 22 May the
necrotic layers had almost completely come away. The wound is
well supplied with blood, some
granulation tissue had begun to
form (Fig. 3). Consistently continuing this treatment, the heel sore
was completely clean by 11 June
(Fig. 4). By 22 June the wound
was markedly flatter and continued to be well supplied with blood
(Fig. 5). Treatment was continued
unaltered until the wound healed
completely (Fig. 6, 14 August).
1
2
3
4
5
6
depends on the size of the dressing. For easy activation of
TenderWet (and also of TenderWet 24), TenderWet Solution
is supplied in convenient sizes of 10, 15 and 30 ml. The
composition of the sterile, pyrogen-free and isotonic solution corresponds to that of Ringer’s solution.
TenderWet 24 is made from the same materials as TenderWet, but is designed so that the absorbent-rinsing action
is sustained for up to 24 hours. To protect the dressing
from strike through, a water-repellent layer is integrated
inside the dressing at 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.
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 Ringer’s solution and can
be applied immediately. This dispenses with time consuming preparations. Another advantage of the already
activated wound pads is that a much greater volume of
Ringer’s solution can be introduced into the absorbent
core than is possible with manual impregnation. As a
result, the wound can be kept moist for longer.
Moreover, the pads are soft and conformable, especially in
the case of TenderWet active cavity, which can be used to
pack even cavernous wounds without difficulty. In contrast,
TenderWet 24 active should not be packed into the wound
because of its water repellent protective layer.
TenderWet 24 active and TenderWet active cavity are already
activated with Ringer’s solution
ready for use.
Hydroactive wound dressings [50.51]
Treatment of a coccyx decubitus
with TenderWet (Case study by
Eduard Rath, Bernried): 84-yearold female patient, diabetes
mellitus, compensated heart failure,
poor general condition, pressure
sore in coccyx region, S/P femoral
neck fracture on both sides.
On admission on 18 March 96, the
pressure sore was necrotic and
purulent with an overt anaerobic
infection, surgical debridement
was performed on 19 March.
On 27 March, treatment of the
wound was changed to the dressing pad TenderWet (Fig. 1),
activated with an antiseptic
instead of Ringer’s 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 Ringer’s 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.
1
2
3
4
5
6
The following applies generally to all TenderWet wound
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).
Sorbalgon – calcium alginate dressings
with excellent conformability
Sorbalgon is the wound dressing ideally suited for cleansing and for supporting the buildup of granulation tissue
in cavernous wounds and wounds in difficult anatomical
sites. By virtue of its excellent packing characteristics,
Sorbalgon also provides effective cleansing and conditioning in deep wounds.
In the treatment of venous ulcers, Sorbalgon is especially
indicated during the period of continuation treatment in
patients who have undergone surgical debridement of
necrotic tissue. Sorbalgon is a nonwoven dressing made of
high-quality calcium 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 provides efficient microbial reduction and helps avoid recontamination. Wounds are swiftly cleansed, and Sorbalgon has
therefore proved especially successful in the treatment of
chronic and infected wounds.
With its gel-like consistency, Sorbalgon also acts like a
moist dressing that prevents the wound from drying out.
The dressing creates a microclimate favourable for wound
healing, promotes the formation of granulation tissue
and keeps the wound surfaces supple.
1
2
3
The principle of action of
Sorbalgon
Hydroactive wound dressings [52.53]
Treatment of a decubitus in the
sacral region, Stage III, with
Sorbalgon (Case study by Friedhelm Lang, Leonberg): Findings
on admission (Fig. 1), the decubitus
underwent surgical debridement.
A large amount of pus was discharged (Fig. 2), a further fistulous
tract had to be incised (Fig. 3).
The wound was packed with
Sorbalgon while the patient is still
in the operating room (Fig. 4).
At the first dressing change, small
necrotic residues were removed
with a scalpel (Fig. 5). The wound
was again loosely packed with
Sorbalgon (Fig. 6), and on the
11th day after debridement, the
defect was well supplied with
blood (Fig. 7).
Four weeks later, abundant granulation tissue had formed, the
wound was clean and infectionfree (Fig. 8). With the above
wound status the patient was
transferred back to the nursing
home from where she was
referred.
1
2
3
4
5
6
7
8
Sorbalgon has excellent conformability qualities and thus also
provides effective cleansing and
conditioning in deeper wounds.
Sorbalgon is available as a
dressing and ribbon.
Sorbalgon’s gel-forming properties prevent it from sticking
to the wound and dressing changes involve little pain.
However, complete gelatinisation of the calcium alginate
fibres requires the presence of sufficient exudate. If cavernous wounds with little exudate have to be packed,
Sorbalgon should be moistened with Ringer’s solution.
Any fibres remaining in the wound can be rinsed out with
Ringer’s solution, otherwise the gel plug is removed from
the wound using forceps.
The frequency of dressing change depends on the individual wound situation. In the wound cleansing phase, 1 to 2
dressing changes may be required depending on the
amount of exudation. Later, as granulation tissue forms, a
dressing change every two to three days may be sufficient.
Sorbalgon is available in two sizes as square dressings.
Sorbalgon T is available as a ribbon.
Sorbalgon dressings loosely
packed in (left) and their transformation into a gel-like structure on
contact with exudate (right)
Hydroactive wound dressings [54.55]
Treatment of decubitus in the
sacral region, Stage III, with
Sorbalgon (Case study by Friedhelm Lang, Leonberg): Findings
on admission (Fig. 1), the decubitus was treated with a gauze
swab.
After its removal, the necrotic
layer was visible on the sacral
bone (Fig. 2).
10 days after surgical debridement and treatment with Sorbalgon, granulation began (Fig. 3/4).
Continued buildup of granulation
tissue (Fig. 5). Wound status
20 days after debridement
and Sorbalgon treatment (Fig. 6),
discharge to domiciliary care.
1
2
3
4
5
6
PermaFoam – hydroactive foam dressing
The PermaFoam foam dressing is indicated for non-infected
wounds with moderate to heavy exudate in the cleansing
phase and during the granulation phase. Its therapeutic
action is based on its special pore structure.
PermaFoam is a combination of two differently structured
foams that are connected with each other by a special
form of lamination. The absorbent layer of PermaFoam
consists of hydrophilic polyurethane polymers that can
store up to nine times their own weight of liquid in their
polymeric chains. The polyurethane matrix has a unique
pore gradient: the large pores on the wound side become
progressively smaller in the direction of the outer coating
layer, which produces strong vertical capillary action. The
outer PermaFoam layer consists a flexible, close-porous
polyurethane foam and is semipermeable, which means
bacteria-proof but permeable to water vapour.
The hydrophilic foam dressing
PermaFoam with its convincing
physical mode of action extends
the range of treatment options for
chronic wounds.
This material combination and design results in product
characteristics which can counteract the maceration problems often observed with chronic wounds: via the strongly
marked vertical capillarity, the surplus aggressive wound
exudate is quickly drawn up to underneath the outer layer.
The large foam pores on the wound side ensure that viscous exudate and detritus are also absorbed without
blocking the pores. When absorbing the wound exudate,
the polyurethane foam swells slightly which ensures the
contact necessary to draw off discharges from the wound
floor.
Hydroactive wound dressings [56.57]
Treatment of toilet seat-shaped
decubitus due to sitting for hours
on the toilet, 83-year-old female
patient (Case study by Friedhelm
Lang, Leonberg)
(1) Findings on admission
(2) State of decubitus after surgical
debridement
(3) – (6) Wound cleansing and
wound conditioning were performed using the foam dressing
PermaFoam, continuous healing
progress was observed.
(7) and (8) Clean granulation
tissue rapidly formed during
PermaFoam treatment. Epithelisation of the defect was equally
rapid from the wound margin,
and the size of the defect steadily
decreased.
Remarkably, despite the patient’s
poor general condition we did not
have to accept any stagnation or
setbacks in the treatment course.
On the 42nd postoperative day
treatment was changed to
Syspur-derm, until the ulcer was
completely closed with stable
epithelial tissue capable of loading within 65 days.
58
1
2
3
4
5
6
7
8
The absorbed wound exudate then spreads out laterally
under the outer layer. In this regard, it is also important
that PermaFoam has – mainly due to the special pore
structure – a high retention capacity for fluids. Even when
pressure is applied from outside by, for example, a pressure
bandage, the exudate is retained in the foam. Also relevant
is the fact that the absorbent capacity of PermaFoam is
only slightly reduced even under the pressure of a compression bandage. For example, under a pressure of
42 mmHg, the absorbent capacity is reduced by only 12 %
compared with the pressure-free condition.
The therapeutic efficacy of
PermaFoam derives from its special
pore structure: large pores on the
wound side become progressively
smaller in the direction of the
outer coating layer, which produces strong vertical capillary
action. As a result, exudate is
rapidly absorbed deep inside the
absorbent pad, but also provides
high retention for reliable fluid
binding.
Taken together, all these characteristics result not only in
the desirable rapid regulation of exudation, but also protect the wound margins from maceration because the
absorbed wound exudates are not pressed back into the
wound again. In addition, the high permeability of the
outer layer to water vapour ensures a well-balanced moist
microenvironment for the wound, which further supports
the healing process.
PermaFoam is atraumatic, sticking to the wound and
growth of tissue into the foam structure are minimised.
Due to the high absorbent capacity and the very good
retention, PermaFoam can – even with profuse exudation
(when no complications exist) – remain on the wound for
several days.
Hydroactive wound dressings [58.59]
2
1
3
Specially for decubitus treatment,
PermaFoam is also available cut
to size for specific therapeutic
requirements:
1) PermaFoam sacral for the
sacral region
2) PermaFoam cavity for packing
deep wounds
3) PermaFoam concave for elbows
and heels
PermaFoam is soft and flexible and therefore clings well to
the wound contours. The dressing is held in place with
elastic dressing retention bandages (e.g. Peha-haft) or over
the entire area with adhesive elastic nonwoven fabrics
(e.g. Omnifix elastic). The product version PermaFoam
comfort is designed for an easy fixation with an adhesive
border. The used adhesive is gentle on the skin. PermaFoam is available in a variety of versions and sizes.
Hydrocoll – absorbent hydrocolloid dressing
Hydrocoll is a self-adhesive, absorbent hydrocolloid dressing for cleansing and conditioning of non-infected wounds
with moderate to heavy exudate.
The term “colloid” comes from the ancient Greek and
means a substance which is integrated in a very finely
dispersed form in a matrix. Hydrocoll therefore consists
of hydrocolloids capable of absorbing and swelling and
are incorporated in a self-adhesive elastomer. A semipermeable film serves to prevent bacterial and moisture
penetration.
The principle of action of
Hydrocoll
The central feature of the mechanism of action of Hydrocoll is the hydrocolloids incorporated in the backing layer.
On absorbing wound exudate they swell to form a gel
which expands into the wound and maintains a moist
wound environment. The gel remains absorbent until the
hydrocolloids are saturated. During the swelling process
the absorbed wound exudate, which is always contaminated with detritus, bacteria and their toxins, is securely
retained within the gel structure.
Hydrocoll is a self-adhesive,
absorbent hydrocolloid dressing
for cleansing and conditioning
non-infected wounds with
moderate to heavy exudate.
For practicable and economical
use, Hydrocoll is available in a
variety of shapes and presentations:
(1) and (2) Hydrocoll concave with
perfect fit for elbows and heels
(3) and (4) Hydrocoll sacral
specially for wound treatment in
the sacral region
Figures (5) – (8) show excerpts
from the course of wound healing
of a Stage II decubitus with blistering on the left heel. Wound care
was provided with Hydrocoll and
was uncomplicated. Because of its
high absorbent capacity, Hydrocoll
could be left on the wound for
several days which made treatment easy and also cost-effective
because of the reduced number of
dressing changes.
(case study by Gabi Michl,
Kötzting)
1
2
3
4
5
6
7
8
Hydroactive wound dressings [60.61]
The adhesive power of the elastomer allows Hydrocoll to
be applied to the wound like an adhesive plaster. When
the gel forms, the adhesive power on the wound surface
disappears, leaving Hydrocoll fixed only on the intact
peri-wound area in a manner atraumatic to the wound.
Hydrocoll is manufactured using hydrocolloids with especially good absorbent and swelling properties, and which
also have the characteristic of retaining a compact gel
structure. Although Hydrocoll expands into the wound, in
the gelatinised state it can be removed from the wound as
an entirely intact dressing. Hardly any gel remnants remain
in the wound, making it only seldom necessary to irrigate
the wound to remove gel residues of pus-like consistency.
This makes dressing change easier and more pleasant.
Moreover, a reliable wound assessment can be made
immediately.
The mechanism of action of Hydrocoll is effective in all the
phases of wound healing:
Since microbially contaminated wound exudate is quickly
taken up into the hydrocolloid structure of the dressing by
the absorbent and swelling process, the wound is rapidly
and effectively cleansed. As general studies have shown,
the microcirculation in the wound area also improves with
progressive cleansing. The body’s own cleansing mechanisms are reactivated especially in chronic wounds in
which the cleansing process is stagnating. During the
granulation phase, the moist wound environment maintained by Hydrocoll stimulates the formation of granulation tissue.
With Hydrocoll, the balanced moist wound environment
can also be maintained without difficulty over prolonged
periods and the granulation tissue is reliably prevented
from drying out.
In the epithelisation phase, the cell-friendly moist wound
environment promotes mitosis and migration of the epithelial cells. In addition, undesirable scab formation which
could delay healing is prevented.
The bacteriaproof and waterproof outer layer forms a reliable barrier against microorganisms and protects the
wound from dirt and moisture. Mobile patients can shower
with the dressing in place. The “Hydrocoll thin” version is
specially suited for already epithelising wounds.
Hydrosorb – transparent hydrogel dressing
Hydrosorb is the ideal wound dressing that keeps the
necessary degree of moisture required by granulation
tissue and fresh epithelium and is best suited for phasespecific continuation treatment after initial wound treatment with TenderWet, Sorbalgon or PermaFoam.
Hydrosorb is a ready-to-use gel sheet dressing made of
absorbent polyurethane polymers which hold a high water
content of 60 %. This allows Hydrosorb to provide the
wound with moisture – actively, with immediate effect and
over several days (1). At the same time, Hydrosorb absorbs
excess secretion which is then trapped within the matrix
of the gel. This humidity-exudate exchange ensures the
optimum moisture level for wound healing and thus accelerates granulation and epithelisation (2). Additionally, the
bacteriaproof and waterproof outer surface of Hydrosorb
provides safe protection from secondary infections.
1
2
The principle of action of
Hydrosorb
Hydroactive wound dressings [62.63]
Hydrosorb does not stick to the wound and its removal
creates no risk of causing wound irritation, even after long
periods of application. Hydrosorb can be removed as an
entirely intact dressing because the gel matrix does not
dissolve as a result of absorbing wound secretions.
No remnants are left on the wound, and an assessment
of the wound condition can be done safely without prior
rinsing.
The transparency of Hydrosorb is particularly advantageous
in the everyday use of this dressing because it is permanent,
even after the dressing has been on the wound for longer
periods. This transparency makes it possible to inspect the
wound at any time without requiring a dressing change.
Thus, the wound is allowed to rest – which is so important
for healing – and great cost-effectiveness is achieved due
to longer time intervals between dressing changes.
Hydrosorb is available in two designs as Hydrosorb and
Hydrosorb comfort. Both hydrogels are based on the same
physical principle of action but differ in their respective
mode of fixation. Hydrosorb does not feature a self-adhesive fixation border and is usually secured by using a
conforming bandage or a compression bandage.
Hydrosorb comfort is provided with a hypo-allergenic
adhesive film border around the edges for secure, bacteriaproof fixation. This, together with the bacteriaproof and
waterproof covering layer of Hydrosorb comfort, simplifies
its use and greatly facilitates daily hygiene.
The transparency of Hydrosorb is
important for its economical use.
The wound can be inspected
through the dressing at any time,
and Hydrosorb can therefore be
left on the wound for days at a
time, and fewer dressing changes
are needed.
1
2
3
4
Example of a Hydrosorb comfort
application (Case study Friedhelm
Lang, Leonberg):
88-year-old patient with decubitus
of the heel. Ulcer status at the
start of treatment exclusively with
Hydrosorb comfort on 10 August
1998 (Fig. 1). After 10 days of
treatment, fresh red granulation
with beginning epithelisation
(Fig. 2-4). The patient was
discharged after 16 days.
Hydroactive wound dressings [64.65]
TenderWet
Sorbalgon
Product characteristics
wound pad with absorbentrinsing core made of superabsorbent polyacrylate is activated
before use with Ringer’s solution,
which is then given off to the
wound in exchange for wound
exudate
excellent conformability, non-medicated, active agent free calcium
alginate dressings that transform
into a moist gel on contact with
wound secretion; the swelling
process also securely traps microorganisms in the gel structure.
Properties and main uses
due to continuous delivery of
Ringer’s solution and simultaneous
absorption of microbially contaminated exudate (= absorbentrinsing effect), rapid active wound
cleansing and promotion of the
proliferation of the tissue cells, for
the treatment of chronic, infected
and non-infected wounds during
the cleansing phase and the beginning of the granulation phase
high absorbency with efficient
cleansing action, after transforming into gel keeps the wound
moist, promotes formation of
granulation tissue, due to excellent conformability ideal for
cleansing and conditioning of
deep and cavernous, infected
and non-infected wounds and
after surgical debridement
Presentations
TenderWet 24 active, sterile,
Ø 4, Ø 5,5, 4x7, 7,5x7,5, 10x10
and 7,5x20 cm; TenderWet
active cavity, sterile, Ø 4, Ø 5,5,
4x7, 7,5x7,5, 10x10 and 7,5x20
cm; TenderWet 24, sterile, Ø 4,
Ø 5,5, 7,5x7,5 and 10x10 cm;
TenderWet, sterile, Ø 4, Ø 5,5,
7,5x7,5 and 10x10 cm
Sorbalgon, sterile, 5x5, 10x10
and 10x20 cm; Sorbalgon T
ribbons, sterile, 1 g/30 cm and
2 g/30 cm
Products for
hydroactive
wound management
PermaFoam
Hydrocoll
Hydrosorb
hydroactive foam dressing
made of differently structured
foams with high vertical
capillary action and retention
self-adhesive hydrocolloid dressing
with particularly absorbent and
swellable hydrocolloids, combined
with semipermeable bacteriaproof
and waterproof cover layer
transparent gel made of
absorbent polyurethane polymers with a high integrated
water content of about 60 %,
combined with semipermeable,
bacteriaproof and waterproof
cover layer
rapid regulation of wound exudates, protects wound margins
from maceration, particularly
suitable for treatment of venous
ulcers in combination with compression treatment for the care
of up to 2nd degree burns. The
specific cut-to-size parts are used
for deeper wounds or problem
zones in difficult anatomical sites
provides good cleansing, improves
microcirculation in the wound
area, promotes formation of granulation tissue, no sticking to the
wound, in the gelatinised state
can be removed from the wound
as an entirely intact dressing,
especially suitable for conditioning non-infectious wounds with
moderate to slight exudate
supplies the wound with moisture
from the outset, its transparency
allows inspection of the wound
at all times without dressing
change (= highly economical due
to prolonged dressing change
intervals), ideal for keeping
granulation and epithelial tissue
moist after treatment with
TenderWet, Sorbalgon or
PermaFoam therapy
PermaFoam, sterile, Ø 6, 10x10,
10x20, 15x15, 20x20 cm;
PermaFoam comfort, sterile,
8x8, 11x11, 10x20, 15x15,
20x20 cm; PermaFoam sacral,
sterile, 18x18, 22x22 cm;
PermaFoam concave, sterile,
16,5x18 cm; PermaFoam
cavity, sterile, 10x10 cm
Hydrocoll, sterile, 5x5, 7,5x7,5,
10x10, 15x15 and 20x20 cm;
Hydrocoll sacral, sterile,
12x18 cm; Hydrocoll concave,
sterile, 8x12 cm; Hydrocoll
thin, sterile, 7,5x7,5, 10x10
and 15x15 cm
Hydrosorb, sterile, 5x7,5, 10x10
and 20x20 cm; Hydrosorb
comfort, sterile, 4,5x6,5, 7,5x10,
12,5x12,5 and 21,5x24 cm
Hydroactive wound dressings [66.67]
Wound dressings for chronic problem wounds / decubitus ulcers
Wound cleansing
Necrosis
Infection
Fibrin layer
Stage I* and II
Exudate ++
TenderWet 24 active
䡲 TenderWet 24 active
䡲 Sorbalgon
䡲 Atrauman Ag with
absorbent wound dressing
Intact peri-wound area
䡲 PermaFoam comfort
䡲 PermaFoam sacral
䡲 PermaFoam concave
䡲 TenderWet 24 active
Pre-damaged
peri-wound area
䡲 PermaFoam
Exudate +
䡲 TenderWet 24 active
䡲 Atrauman Ag with
absorbent wound dressing
䡲 TenderWet 24 active
Stage III and IV
Exudate ++
TenderWet active cavity
䡲 TenderWet active cavity
䡲 Sorbalgon/Sorbalgon T
䡲 Atrauman Ag with
absorbent wound dressing
䡲 TenderWet active cavity
䡲 PermaFoam cavity
䡲 Sorbalgon/Sorbalgon T
Exudate +
䡲 TenderWet active cavity
䡲 Atrauman Ag with
absorbent wound dressing
䡲 TenderWet active cavity
Granulation
Epithelisation
Intact peri-wound area
䡲 PermaFoam comfort
䡲 PermaFoam sacral
䡲 PermaFoam concave
Pre-damaged
peri-wound area
䡲 PermaFoam
Intact peri-wound area
䡲 Hydrocoll thin
䡲 Hydrosorb comfort
䡲 Hydrofilm
Pre-damaged
peri-wound area
䡲 Hydrosorb
Intact peri-wound area
䡲 Hydrocoll
䡲 Hydrocoll sacral
䡲 Hydrocoll concave
Pre-damaged
peri-wound area
䡲 Hydrosorb
䡲 PermaFoam cavity
䡲 Sorbalgon/Sorbalgon T
䡲 PermaFoam cavity
Further products
Cosmopor sterile
Self-adhesive wound dressing
with high absorbency and good
padding effect for postoperative
wound management and for
sterile treatment of minor injuries
Hydrofilm plus
Self-adhesive, waterproof, transparent film dressing with good
absorbency and padding effect for
postoperative management of
lightly exuding wounds and for
protection against secondary
infections
Dressing retention
Normal skin:
Omnifix elastic, Omniplast,
Omnisilk, Peha-haft, Stülpa-fix
Sensitive skin:
Pehalast, Omnipor, Peha-crepp,
Extremities:
Peha-haft**, Pehalast, Stülpa-fix
Sacral region:
Omnifix elastic, Molipants
(Inco-System), Stülpa-fix
* Skin protection for Stage I
Hydrocoll thin, Hydrofilm,
Menalind professional
skin protection foam
Intact peri-wound area
䡲 Hydrocoll thin
䡲 Hydrosorb comfort
䡲 Hydrofilm
Pre-damaged
peri-wound area
䡲 Hydrosorb
** Warning: Since Peha-haft is a cohesive
conforming bandage, it should be used
with care in patients with disturbed blood
circulation. Do not apply too tightly.
Hydroactive wound dressings [68.69]
Nursing activities for
decubitus prophylaxis
The activities required for the prevention of pressure ulcers
can be divided into five main categories:
Recognise the risk of pressure sore!
The following simple rule can be applied: The less mobile a
person, the greater the risk of a pressure ulcer developing.
If risk factors such as fever, incontinence or a debilitated
general condition are also present, great alertness is needed. In daily nursing activities, the extended Norton scale
has proved a reliable instrument for estimating the risk of
decubitus (see also page 17).
Observe the skin!
The patient’s skin should be inspected at least once daily
for signs of incipient exposure to pressure. The first signs
are white or red, sharply defined areas of skin (see page
16). The classical pressure ulcer localisations such as the
sacral region, trochanter and heels should be examined
especially closely. At the first signs, pressure relief should
be commenced immediately.
Pressure-relief positioning!
There is only one means of effectively preventing pressure
sores: eliminate exposure to pressure. This can be achieved
by repositioning, soft positioning or free positioning; these
individual expedients can also be combined to achieve the
greatest degree of safety.
Repositioning in effect replaces the lacking or inadequate
movement of the body. Patients are usually repositioned
in a two-hourly rhythm. If the risk is particularly great,
Schematic diagram of pressure
distribution on a firm mattress
(top) and the pressure relieving
effect of a soft mattress (bottom)
however, it may be necessary to shorten this time interval.
Conversely, when there is a low risk of pressure ulcer, it is
possible to extend the repositioning interval through the
additional use of extremely soft positioning.
The 30 degree oblique position, alternately right or left, is
now preferred as the positioning that involves the lowest
risk (see also page 28). The 90 degree lateral position, on
the other hand, is now considered obsolete, because most
of the body’s weight is then bearing on the trochanter.
Soft positioning is performed with the aid of special
mattresses, support surfaces and pillows into which the
patient can sink down. The bearing pressure of the body is
then distributed over a greater area, resulting in pressure
relief. In free positioning, sites of the body that are particularly at risk, such as the heels, are positioned free of
contact and are therefore completely relieved of pressure.
Safely usable positioning aids are also available for free
positioning.
Prophylactic activities [70.71]
Mobilise the patient!
Immobility is the greatest risk factor. Everything possible
should therefore be done to mobilise the patient as rapidly
as possible or maintain any residual mobility, e.g. by
performing sitting exercises and passive and active movements in bed; for severely ill and absolutely immobile
patients, repositioning every two hours is also a valuable
form of mobilisation.
Intensify skin care!
Healthy skin is more resistant to pressure stress than skin
with existing damage, and should therefore be given particularly close attention in the classical pressure sore areas.
Especially dried skin of the elderly should not be dried
further during washing and should be protected by the use
of cleansing and conditioning preparations with highly
oil-restoring additives. To stimulate blood circulation of the
healthy skin, light massages and embrocations may be
used, but icing and fanning of the skin should be avoided.
If alcohol-containing embrocations are used, the skin
should be treated with an oil restorative afterwards to
prevent drying out. Skin macerations due to incontinence
can be prevented by using adequate incontinence products and careful skin care.
Supplementary aids for
treatment and nursing care
Aids for dressing change
A large number of practical aids are available to make the
process of changing dressings safer and easier: Disposable
gloves in various qualities reflecting the different requirements for wound management, sterile and unsterile,
cotton-tipped applicators, tweezers, disposal bags for
contaminated material, drapes to create sterile working
surfaces, mouth and nose protectors etc.
A number of fixation aids are also available for the retention of wound dressings in different therapeutic situations:
The nonwoven dressing retention sheet plaster Omnifix
elastic, for example, is ideal for wide-area coverage. The
transparent and bacteriaproof film dressing Hydrofilm, on
the other hand, is highly suitable for full-area coverage of
wounds in areas exposed to microbial contamination, such
as the sacral region, and offers safe protection against
secondary infections. The cohesive elastic conforming
bandage Peha-haft is indispensable for the fixation of, for
example, TenderWet on the heels. Peha-haft is easy to
apply even on this difficult to dress part of the body and is
non-slip due to its cohesive coating. If fixation tapes are
required, the skin-friendly surgical adhesive tapes Omniplast, Omnisilk, Omnipor and Omnifilm are outstandingly
suitable for this purpose.
Caution: As a cohesive dressing
retention bandage Peha-haft is to
be used with care in patients with
blood circulation disorders and
should not be applied too tightly!
Supplementary aids [72.73]
1) Peha-soft powder-free:
Disposable gloves made of latex,
one example of the wide range
of disposable gloves
2) Cotton buds: in various styles,
useful aids for wound cleansing
3) Peha disposable forceps: made
of plastic anatomically shaped,
indispensable for dressing change
4) ValaComfort mask: mouth and
nose mask made of nonwoven,
for infection prophylaxis on dressing change
5) Foliodrape drapes: in various
qualities, for sterile draping of
patients and surfaces
6) Pagasling: twisted gauze swabs
of high absorbency, ideal for
cleansing wounds
7) Omnifix elastic: skin friendly
nonwoven fixation sheet for
simple full-area dressing retention
also on conical parts of the body
8) Hydrofilm: film dressing for
full-area coverage of wounds
9) Peha-haft: cohesive-elastic
conforming bandage, stays reliably
in place without end fixation and
is particularly economical in use
10) Omnipor: hypoallergenic
surgical adhesive tape made of
nonwoven, suitable for very
sensitive skin
1
2
3
4
5
6
7
8
9
10
Menalind professional –
care and protection of the skin
The importance of intensive skin care for maintaining the
health especially of elderly skin cannot be emphasized
enough. The Menalind cleansing, conditioning and protection products offer a reliable form of care because all the
products are specifically formulated to meet the needs of
the skin of the elderly. The Menalind ingredients such as
oil-restoring substances, D-panthenol and creatine support
the regeneration of the skin and promote the maintenance
of its health. All products are clinically tested.
Menalind professional comprises three product lines:
䡲 Menalind professional cleansing products –
wash lotion, shampoo, skin care bath, skin cleansing
foam, moist skin care tissues and body cleansing wipes
䡲 Menalind professional care products –
hand cream, skin fluid, skin care oil, body lotion and
oil bath
䡲 Menalind professional –
skin protection foam, skin protection cream and
skin protection oil spray
Supplementary aids [74.75]
The HARTMANN Inco System helps
prevent skin traumatisation
Urinary incontinence places great stress on the skin for a
variety of reasons and is thus a risk factor for the causation of pressure ulcer. Moisture and the aggressive breakdown products of urine irritate and soften the skin. The pH
becomes increasingly alkaline, the skin becomes increasingly permeable to water soluble substances, and bacterial
contamination increases. An important goal of incontinence care is thus also to prevent this damage to the skin.
The skin must therefore be kept as dry as possible, which
can only be assured by using high quality incontinence
products.
All incontinence products from HARTMANN, through their
material components and product design, offer maximum
safety: The odour-binding superabsorbent core rapidly
absorbs liquid and the fluid distribution layer made from
the special Dry-Plus nonwoven protects against rewetting
and keeps the skin drier.
The HARTMANN Inco system includes products for all
degrees of severity of incontinence, with the aim of ensuring patient individualized and economical care under all
conditions: MoliMed for men incontinence pads for men,
MoliMed absorbent pads for slight incontinence, MoliForm
incontinence pads for slight, moderate, severe and very
severe incontinence, MoliForm for men incontinence pads,
MoliCare all-in-one incontinence briefs for severe and very
severe incontinence, MoliCare Premium all-in-one incontinence briefs with breathable nonwoven fabric layer in the
hip region, MoliCare Med all-in-one incontinence briefs
containing an inner top layer of panthenol-treated nonwoven fabric and MoliCare Mobile incontinence pants
which can be pulled on and off like normal underwear.
Glossary and list of key terms
A
D
H
Acute ➞ sudden, rapidly
occurring onset of the disease
Debridement ➞ 31
Hydroactive wound dressings
➞ 46 f
Adjuvant ➞ supporting helping,
e.g. adjuvant therapy
Affinity ➞ tendency (attraction)
towards someone or something
Age of the patient ➞ 14
Anamnesis ➞ systematic
questioning (of the patient)
Anemia ➞ lack of blood deficiency of red blood corpuscles or
blood pigment (haemoglobin)
Decubitus classification ➞ 18
Decubitus localisation ➞ 9
Decubitus prophylaxis ➞ 70
Hydrocoll (hydrocolloid dressing)
➞ 60
Decubitus risk ➞ 10 f
Hydrophilic ➞ water-absorbing,
water loving
Defect coverage, plastic surgery
➞ 37
Hydrosorb (hydrogel dressing)
➞ 63
Degree of severity, Stage I
➞ 18
I
Degree of severity, Stage II
➞ 18
Immobility, total ➞ 12
Immobility, elative ➞ 12
Incontinence ➞ 13
Assessment of the patient’s status
➞ 22 f
Degree of severity, Stage III
➞ 18
Autolysis ➞ ability of dying cells
to digest themselves by releasing
certain enzymes without the
involvement of bacteria
Degree of severity, Stage IV
➞ 19
Induced ➞ introduce, instigate
med.: cause, trigger
Documentation ➞ 43
Infection control ➞ 34
Dressing change ➞ 73
Infection prophylaxis ➞ 34
E
Insufficient blood supply ➞ 13
Epithelisation phase ➞ 37
Irreversible ➞ cannot be
changed back, cannot be undone
C
Cachexia ➞ emaciation due to
severe loss of weight, decay of
strength resulting from certain
underlying diseases
Causal ➞ the reason for
Estimation of decubitus risk
➞ 16
Inco-System ➞ 76
Ischemia ➞ emptiness of blood
F
M
Cleansing phase ➞ 31
Factors interfering with wound
healing ➞ 39 f
Maceration ➞ swelling, softening e.g. of wound margins
Convex ➞ bulging, rounded
Fever ➞ 13
C-reactive protein (CRP) ➞ acute
phase protein formed by the liver,
used as a parameter of inflammation
G
Malnutrition ➞ incorrect or
deficient diet
Causes of pressure ulcer ➞ 6 f
General physical condition ➞ 22
Granulation phase ➞ 35
Management of pressure ulce ➞
20 f
Menalind professional ➞ 75
Glossary and index of key terms [76.77]
Migration ➞ travelling, moving
med.: cell migration
Mitosis ➞ process of cell
division in somatic cells
Multimorbiditiy ➞ simultaneous
presence of several diseases
N
Nursing activities ➞ 70
Nutritional status ➞ 24
O
Obsolete ➞ out of date, no
longer current no longer complying with the rules of medical
science
Operation-specific risks ➞ 14
Overt ➞ clearly evident, obvious
med.: the becoming evident of a
disease due to the corresponding
symptoms
P
Pain ➞ 26
Pathological ➞ disease related,
deviating from normal
Patient status ➞ 22
PermaFoam (hydroactive foam
dressing) ➞ 57
Pressure relief ➞ 27 f
Proliferation ➞ growth of tissue
by propagation resulting from
inflammatory processes e.g.
during wound healing following
the inflammatory phase
Psychosocial assessment ➞ 26
R
Recurrent ➞ occurring again
and again med.: relapsing of a
disease after it has healed
Relevance ➞ importance,
significance of a thing or
circumstances
Risk factors ➞ 10 f
S
Sites of predilection ➞ sites of
the body preferentially affected by
a disease process
Skin care and protection ➞ 75
Sorbalgon (highly comfortable
calcium alginate dressings) ➞ 53
T
Tangential ➞ touching a curved
surface or line
Tenderness ➞ pain caused by
mechanical pressure on part of
the body, diagnostically useful
TenderWet (wound pad with
superabsorber) ➞ 48
Toxic ➞ poisonous
W
Wound dressing ➞ 46 f
Wound treatment ➞ 30 f
References
Farhadi; J., Pierer, G.: Plastisch-chirurgische Konzepte
zur Deckung von Dekubitalulcera (II), in HARTMANN
WundForum 1/2005
Lang, F., Röthel, H.: Das Dekubitalulcus – Ursachen,
Prophylaxe und Behandlung, in HARTMANN WundForum
2/1999
Seiler, W. O.: Dekubitus-Pathogenese und Prophylaxe (I),
in HARTMANN WundForum 3/2002
Seiler, W. O.: Dekubitustherapie mit System (II), in
HARTMANN WundForum 4/2002
Seiler, W. O., Stähelin, H. B.: Dekubitus, in Sedlarik, K. M.
(Hrsg.): Wundheilung, Gustav Fischer Verlag, Jena/
Stuttgart, 1993
Seiler, W. O., Seiler, D. W.: Katabolismus: Hauptstörfaktor
der Wundheilung im Alter, in HARTMANN WundForum
1/2001
Winter, H., Nusser, B.: Problemwunden – Herausforderung
für Medizin und Pflege (V), in HARTMANN WundForum
1/2005
References [78.79]
List of illustrations
Brookes, A. / Corbis (p. 1)
Farhadi, J. (p. 38)
Feingersh, J. / Corbis (p. 6)
Lang, F. (p. 20, 22, 33, 47, 54, 56, 58, 65)
Lück GmbH, Bocholt (p. 29)
Michl, G. (p. 61)
Rath, E. (p. 52)
Seiler, W. O. (p. 42)
according to illustrations from Straub, G. in:
Die Schwester/Der Pfleger 7/84 (p. 11)
Wagner, A. (p. 50)
All other illustrations from the archive of
PAUL HARTMANN AG
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At a time of rapidly evolving
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HARTMANN medicaledition – Phase-specific wound management of decubitus ulcer
PAUL HARTMANN AG
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Phase-specific
wound management
of decubitus ulcer
The HARTMANN medical edition
series of publications deals with
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Wound Management