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1. Alice Pomidor, MD, MPH
Department of Geriatrics
Florida State University College of Medicine
Copyright 2010, Florida State University College of Medicine. This work was supported by a
grant from the Donald W. Reynolds Foundation. All rights reserved.
Pressure Ulcers, Skin
and Wound Care

2. Objectives
 Identify normal changes in aging skin and their
clinical impact
 Recognize risk factors for skin damage and
pressure ulcers
 Use the staging system for wounds
 Choose pressure relief devices and strategies
 Apply the 7 basic principles of wound care
 Recognize different wound care products and
their appropriate applications

3. Case: Mrs. G
 78 year old female type II diabetic
hypertensive with hyperlipidemia, probable
peripheral vascular disease
 Meds: felodipine, lisinopril, glyburide, aspirin
 Spot on foot, another on sacrum, recent
purulent drainage from foot
 Lived alone b/f hospitalized for hip Fx,
smokes ½ ppd x 40 years, was indep ADLs
 Pulses present 2+ carotids and radials, 2+
femorals, trace popliteals, DP & PT not
palpable bilaterally

4. Right foot

5. Increasing Age
Dermis:
Less blood supply
Less elastin, collagen
20% less thickness
10 – 20% fewer
melanocytes/decade
Clinical Effects:
Delayed wound healing
High prevalence of xerosis
Skin tears and blisters easily
Prone to sun damage, malignancy
Epidermis:
Less moisture
50% slower turnover
Flattened dermal-
epidermal junction
Skin Changes with
Aging

6. Risk Factors
 Decreased mobility
 Poor nutrition/hydration
 Vascular compromise
 Sensory impairment
 Multiple medical comorbidities
 Pressure: unrelieved on any firm surface
 Moisture: incontinence, in skin folds
 Friction: dragging across sheets, agitation
 Shear: sliding down in bed. pushing up w/heels

7. Describe & measure
accurately
 Look!
 Must see base of wound
 The presence of necrotic material
means the wound cannot be staged: “at
least” a stage III
 Record all 3 dimensions of length, width
and depth

8. Stage I: Erythema not resolved w/in 30 min pressure relief.
Epidermis remains intact. Reversible with intervention.
Stage II: Abrasion, blister, or shallow crater w/ partial-
thickness skin loss of epidermis and/or dermis. No
subcutaneous necrosis.
Stage III: Crater unless covered by eschar. Full-thickness
skin loss through the dermis into subcutaneous tissue.
Stage IV: Deep crater, tissue destruction extending to
fascia, possibly including muscles, tendons, joint capsule,
and/or bone.
Wound Staging

9. Describe/measure wound accurately
Put the patient in the right place at the right time
Achieve a clean, uninfected wound
Provide a moist environment suitable for healing
Minimize disruption of wound surface
Prevent damage to viable tissue: SALINE!
Feed, water, oxygenate the patient to
compensate for fluid and calorie loss
Wound Care Principles

10. Put the patient in the right
place at the right time
 Choose appropriate support surfaces
 Change positions q2h when supine &
q1h when up
 Reevaluate the wound q1-2 weeks

11. Extremity padding
Heelbo/Elbo
Ankle ring
Heel pillow
Multipodus splint

12. Pressure Relief
Seating
Gel
Foam
Roho
Eggcrate
Sheepskin

13. Pressure Relief Beds
Low Air Loss
Air-fluidized
Alternating
mattress overlay

14. Describe/measure wound accurately
Put the patient in the right place at the right time
Achieve a clean, uninfected wound
Provide a moist environment suitable for healing
Minimize disruption of wound surface
Prevent damage to viable tissue: SALINE!
Feed, water, oxygenate the patient to
compensate for fluid and calorie loss
Wound Care Principles

15.  Macrodebridement
– Sharp vs. blunt
– Maggots
 Microdebridement
– Wet-to-dry dressings
 Enzymatic debridement
– Collegenase
– Papain
 Autolytic debridement
– Occlusive dressings
“ Clean” Wound

16. Dressings-Gauze

17.  All wounds are colonized
 No surface cultures; deep cultures OK
 Anaerobic organisms plus skin flora
 Cellulitis—reactive vs. infective
hyperemia
 Consider osteomyelitis if less than 1 cm
from a bony surface and/or no healing
in 3 months
 Local agents only reduce overgrowth
(silver, metronidazole, mesalt)
Uninfected Wound

18. Describe/measure wound accurately
Put the patient in the right place at the right time
Achieve a clean, uninfected wound
Provide a moist environment suitable for healing
Minimize disruption of wound surface
Prevent damage to viable tissue: SALINE!
Feed, water, oxygenate the patient to
compensate for fluid and calorie loss
Wound Care Principles

19. Moist environment
 If it’s wet, dry it (alginate, hydrofiber,
foam)—excess drainage apparent
 If it’s dry, wet it (hydrogel)—secondary
film of dried material will become visible
 If it’s just right, keep it that way
(hydrocolloid or hydrogel)

20. Minimize disruption
 Dressing changes traumatize the healing
wound surface
 Goal: once per day
 Better: even less often!
 Also more cost effective when accounting
for nursing time

21. Barrier Creams
Ointments
Dessicators,
Antiseptics
Enzymes
Protease Inhibitors
Platelet
Growth Factor
Creams & Ointments

22. •Zinc, A&D, petroleum
•Dakin’s solution, iodoform, peroxide
•Silvadene, metronidazole, antibiotic
Creams & Ointments

23. Antiseptic
Dressings
Impregnated
Gauzes
Thin Films:
Opsite, Tegaderm
Foam
Wafers
Dressings/Films

24. Dressings/Films

25. Dressings/Films

27. Hydrocolloids
Hydrogels
Alginates,
hydrofibers
Biologicals
& Grafts
Gels, Colloids plus

28. Gels, Colloids, Alginates,
Biologicals

31. Describe/measure wound accurately
Put the patient in the right place at the right time
Achieve a clean, uninfected wound
Provide a moist environment suitable for healing
Minimize disruption of wound surface
Prevent damage to viable tissue: SALINE!
Feed, water, oxygenate the patient to
compensate for fluid and calorie loss
Wound Care Principles

32. Preserve viable tissue
 Everything except saline is cytotoxic in
wet-to-dry dressings
 Always use saline for cleansing
 Beware of commercial cleansers or
antibiotic topicals
 Protect the surrounding skin (tape
anchors, petroleum)
 Shield wound/skin from incontinence

33. Feed, water and
oxygenate
 Stress-level protein/calorie replacement
– 1.5 gm/kg/d of protein
– 30 kcal/kg/d
 Minimum 125% daily fluid requirements
for insensible loss & drainage
 Consider transfusion for Hgb <9.0
 Keep blood sugars below 200
 Assess nutrition by Hgb & prealbumin
q2 wks

34. Compression: Ted hose, Jobst stockings, etc.
Support surfaces: Foam, gel, air and fluid-filled, etc.
Negative pressure therapy: lg, high-exudate wounds
Hydrotherapy: whirlpool debridement
Hyperbaric oxygen: anaerobic, radiation, salvage sites
Electrotherapy: low-intensity DC, AC. Limited data and
reimbursement
Ultrasound: results equivocal at best
Supplements: pentoxifylline, zinc, vit. C, oxandrolone
Adjuvant Therapies

36. Mrs. G’s studies
 Labs:
– Glucose 200-280’s
– Basic metabolic panel otherwise normal
– Hgb/Hct 10/ 30
– WBC 14.9, no shift
– Albumin 3.0
 X-ray: Negative for osteomyelitis
 Dopplers: Significantly impaired arterial blood flow,
right greater than left
 Arteriogram: Significant disease of the trifurcation,
reconstituted below with collaterals

37. Mrs. G’s treatment
plan
 Use silver alginate/hydrofiber daily to the foot to
keep it moist
 Debride sacral wound until the base can be seen;
consider enzyme to assist break up of slough
 Refer to vascular surgeon for evaluation of possible
femoropopliteal bypass later
 If bone visible on sacrum, IV antibiotics for possible
osteomyelitis followed by oral therapy for total 8
week course
 Start protein supplement and check prealbumin,
Hgb 2 weeks later
 Reduce blood sugars by increase in oral therapy
and use of sliding scale insulin to target range
150’s

38. Mrs. G’s treatment
plan
 Use extremity padding of some type; order mattress
overlay
 Consider physiatry consult for weight-bearing
reduction orthotic for right foot as well as usual hip
rehab therapy
 Encourage to walk to increase blood flow
 Check fasting lipid profile
 Reduce blood pressure with ACE inhibitor
 Encourage to stop smoking
 Consider subacute/nursing home placement for wound
care and physical therapy

39. Objectives
 Identify normal changes in aging skin and their
clinical impact
 Recognize risk factors for skin damage and
pressure ulcers
 Use the staging system for wounds
 Choose pressure relief devices and strategies
 Apply the 7 basic principles of wound care
 Recognize different wound care products and
their appropriate applications