medicaledition

PAUL HARTMANN AG
P.O. Box 14 20
The HARTMANN medical edition
series of publications deals with Phase-specific
89504 Heidenheim
current subjects from the areas
of medicine and nursing. wound management
Germany They emphasise not only basic
knowledge, but also present
of decubitus ulcer
specialist and interdisciplinary
developments. The information
goes beyond the products and
is particularly important.

HARTMANN medicaledition – Phase-specific wound management of decubitus ulcer

At a time of rapidly evolving
scientific knowledge, information
must above all be up to date.
With this in mind, this series of
books aims to be a source of
advice not only for experienced
workers. Those who are approach-
ing new areas of medicine and
nursing for the first time are
shown modern treatment methods
and are given useful tips.

B34 (0708) 086 XXX/X

ISBN 978-3-929870-68-8

Wound Management
Phase-specific
wound management
of decubitus ulcer
 Table of contents
Published by
PAUL HARTMANN AG Preface 5
89522 Heidenheim
Germany
http://www.hartmann.info Development of decubitus – a multifactorial process 6
– Common sites of decubitus ulcer formation 9
Concept, design, editing and – Decubitus hazards and risk factors 10
production:
CMC Medical Information – Classification and degrees of severity of decubitus 18
89522 Heidenheim
Germany Management of decubitus – general principles 20
– Relief of pressure as the basis of all treatment 27
Scientific supervision:
Prof. Dr. med. Walter O. Seiler, – Phase-specific moist wound treatment 30
University Geriatric Clinic; – Identification and treatment of factors interfering with wound healing 39
Basel Cantonal Hospital
Friedhelm Lang, Hydroactive wound dressings for phase-specific, moist wound treatment 46
Head of Surgical Department
Leonberg District Hospital – TenderWet – wound pad with superabsorber 48
– Sorbalgon – calcium alginate dressings with excellent conformability 53
© PAUL HARTMANN AG – PermaFoam – hydroactive foam dressing 57
May 2008 – Hydrocoll – absorbent hydrocolloid dressing 60
2nd edition
ISBN 978-3-929870-68-8 – Hydrotul – hydroactive impregnated dressing 63
– Hydrosorb – transparent hydrogel dressing 65
Translated from the German – Hydrosorb Gel – for dry wounds rehydration 68
edition (ISBN 978-3-929870-62-6) – Atrauman Ag – silver containing ointment dressing 69
Paper bleached by a chlorine-free – Zetuvit Plus – wound dressing for heavily exuding wounds 70
process
Nursing activities for decubitus prophylaxis 78

Supplementary aids for treatment and nursing care 81

Glossary and list of key terms 85

References and list of illustrations 87

[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 clin-
ical studies to elaborate guidelines for practicable prophy-
lactic and therapeutic activities and establish them as
standard practices.

Despite these efforts, pressure ulcer with an annual inci-

dence of 150,000 cases in Stages III and IV still remains a
major problem for a number of reasons. The growing num-
ber 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 know-

ledge 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 decu-
bitus 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 result-
ing 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 counterpres-
sure 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 high-
er 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 inter-
rupt 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, anes-
thesia, severe dementia and/or if they are no longer strong
enough to move unaided in response to pain, the com-
pression 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 regen-
Development of decubitus [6.7]
Causes of pressure sore: risk factors such as the degree of immobility, the condition
For short periods, the skin can of the skin, various basic illnesses etc. What specific risk
Pressure / pressure exposure time
survive exposure even to heavy
pressure without being damaged. factors are involved and what role they play in causing
If the pressure persists, however, local impairment of blood flow pressure sores are considered in the section „Decubitus
the affected skin cells become hazards and risk factors“ on page 10 onwards.
completely ischemic because of oxygen deficiency / increase in toxic
the increasing impairment of metabolism products
blood circulation and the skin Common sites of decubitus ulcer formation
cells die. increase in capillary permeability, Depending on where the skin is exposed to pressure, a
vascular dilatation, cellular infiltration,
pressure ulcer can develop anywhere on the body. The
edema formation
risk is greatest at those sites, however, where the bearing
blister formation pressure of the body and the counterpressure exerted by
the supporting surface act perpendicularly on an area of
complete ischemia,
irreversible death of skin cells skin located over convex skeletal regions which have little
pressure dispersing elastic muscle and subcutaneous fatty
Ulcer / necrosis
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
erating completely because the inflammatory responses trochanter and the lateral malleoli.
promote the elimination of the toxic metabolism products.
If exposure to pressure remains, however, the worsening
Examples of “classical” sites of
ischemia and hypoxia result in irreversible death of the predilection for pressure sores:
skin cells with necrosis and ulcer formation. 1) Sacral region
The main causes of pressure ulcer are thus the factors 2) Heel
3) Trochanter
pressure x time acting on a given area of skin.
4) Lateral malleolus

Clinically relevant factors in this respect are the degree of

pressure and the length of time. A high degree of pressure
1 2
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 aver-
3 4
age tolerance range of the skin is subject to considerable
variations which are determined by the individual patient’s
Development of decubitus [8.9]
Another characteristic feature of pressure acting on convex The commonest pressure
bony contours is that the pressure increases from the sore localisations

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 ulcer develops preferentially over bony prominences hardly
pressure in the tissue to a critical level (Bennet et al., von
cushioned by muscle and subcutaneous fatty tissue. These are
Goosens et al.).  in dorsal position: sacral bone and coccyx, heels and Achilles tendons,

elbows, shoulder blades and occipital bone

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.
 in abdominal position: frontal bone, elbows, breastbone and costal
arches, iliac crest, kneecaps and tips of the toes
 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
 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, anes-
thetised 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 re-
stricted, 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 illness-
es 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 fac-
tors, 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 second-
ary 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, incor-
rect to assume that incontinence alone can cause a pres-
sure sore. The causal factor in pressure ulcer is pressure,
and incontinence is a contributory factor.
Debilitated general condition: Chronic or severe illness-
es, malignant processes, infections, malnutrition character-
ized by protein, vitamin and zinc deficiency, anemia, exsic-
cosis, 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 co-
existing 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 for-
mation 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, opera-
tion-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 them-
selves include existing skin damage, e.g. due to confine-
ment 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 reposition-
ing (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 sup-
port, patient hypothermia, incorrect use of disinfectants
(especially in the coccyx region, which can also lead to
excessive cooling of the skin because iodine- and alcohol-
containing 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
■ Hypovolemic shock
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 Physical state Incontinence Activity Mobility Psychological
Estimating each patient’s risk of developing a pressure state
ulcer is the first step in planning of prophylaxis.
4 good 4 none 4 no assistance 4 completely 4 clear
This activity may be assisted by using various rating scales required
such as the Norton scale, the Waterlow scale or the
Braden scale. In Germany, the extended Norton scale is 3 fair 3 sometimes 3 possible with 3 hardly 3 apathetic /
assistance restricted disinterested
widely used in medical nursing, while the Waterlow scale
relates more specifically to the risks of surgical patients. 2 poor 2 usually urine 2 wheelchair 2 very restricted 2 confused
The Braden scale is used more commonly in the USA. required

1 very poor 1 urine and 1 bedbound 1 completely 1 stuporous

Common to all these scales is that they take similarly into feces restricted
account the patient’s mental and physical state as well as
their level of activity and mobility, and are thus all useful Willingness to Age State of the skin Concomitant diseases
instruments. It should be noted, however, that the assess- cooperate
ment of hazard from pressure ulcer and hence the delivery
4 completely 4 < 10 4 normal 4 none
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 3 few 3 < 30 3 scaling dry 3 immune weakness, fever,
diabetes, anemia
intervals to allow timely identification of changes and
a suitable response to be made in terms of modifying 2 partially 2 < 60 2 moist 2 MS, Ca, elevated hematocrit, obesity
activities. The assessment of pressure ulcer hazard is thus
part of a thorough program of documentation. 1 none 1 ≥ 60 1 allergy wounds, 1 arterial occlusive disease
fissures

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 clas-
sifications are used, such as Daniel’s classification into five
degrees of severity, which is used particularly in the surgi-
cal field, or the most commonly used classification into
four degrees of severity developed by the “National Pres-
sure 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 red-
dening 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 affect-
ed. Clinically, the pressure ulcer looks like an open sore
with or without undermining of the surrounding tissue.
Classification of the severity of
pressure ulcer is based on which
Epidermis
tissue layers have already been
destroyed by exposure to pressure.
Stage I
Dermis 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 intraop-
erative 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 care-
fully 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 ade-
quate 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
Treatment
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 Ulcer healing?
condition, possible complications and concomitant dis-
eases, the nutritional status, the severity of any pain, but
also a careful inventory of the psychosocial situation.
General physical condition: Wound healing is not mere-
ly 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
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
Course of treatment for decubitus ulcer supervision
yes
and continuation of therapy according to treatment
schedule
no 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 Record form for assessment of decubitus
improvement in the general condition cannot always be
achieved within a short time, and may even be severely
Name
impaired, for example in multimorbid geriatric patients.
Age
In practice, the necessary data can be obtained from the
patient’s medical record and if not, are to be elicited by Date / time of recording

taking a careful and comprehensive medical history and Size

conducting a physical examination. Length breadth depth

With pressure ulcers, moreover, the physician should be

alert to the possibility of complications, such as endo-
Severity / structures affected
carditis, meningitis, septic arthritis, pocket and abscess
❏ Stage I: skin reddening with intact epidermis
formation, malignant processes in the ulcer area, and for
❏ Stage II: superficial ulcer, partial loss of epidermis as far as dermis
systemic complications of the topical therapy, such as ❏ Stage III: deep, open ulcer, damage to all skin layers as far as the fasciae
iodine toxicity or allergy. Serious complications associated ❏ Stage IV: extensive tissue necroses, damage to all skin layers including
with infection include osteomyelitis, bacteremia and muscles, tendons and bones
generalized sepsis.
Yes No
Pocket formation
Nutritional status: Numerous studies have established Undermining
a relationship between the poor healing tendency of pres- Necrotic tissue: closed black necrotic cap
sure sores and malnutrition. Cachectic states associated scab
with protein deficiency, however, are observed particularly slimy layers
Exudate: serous-bloody
often in elderly persons, and the nutritional status should purulent
therefore be evaluated at regular intervals in these cases. Granulation: loose, spongy
Elderly patients are often also suffering from zinc deficiency red, firm
which can also lead to delays in wound healing and Epithelium formation visible
Pain
should therefore be checked. Signs of infection: III sligt reddening
III reddening, swelling, pain
Malnutrition should be treated, taking into account the III plus fever, leukocytosis
patient’s wishes, by providing adequate dietary intake
Causation
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 kilo-
gram of body weight and per day (Seiler, 2001): 30 to
General condition / other
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.)
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 decu-
bitus patient is being treated in hospital, in a nursing facil-
ity 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 situ-
ation, however, sometimes presents greatly differing base-
line conditions in terms of the patient’s ability to fully
understand the therapeutic requirements and “cooperate”
with the treatment. The aim of the psychosocial assess-
ment 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 psy-
chosocial 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 nurs-
ing 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 expo-
sure 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 treat-
ment 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 imme-
diate 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 press-
ure 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 correct positioning of the
patient depends on the localiza-
tion of the decubitus ulcer.
The basic positioning variants
shown here are also suitable
for prophylaxis.
Decubitus localisation
Right trochanter
Left trochanter
Sacral region
Heel
Ischial bone
The 90 degree oblique positioning should no longer be Examples of positionings for
used, either for prophylaxis or for treatment, because most pressure relief with the aid of
special cushions: Due to its special
of the body’s weight then bears on the trochanter. Even design, the cushion bed (left)
before beginning any treatment, therefore, the type of offers effective pressure relief for
positioning suitable for each patient should be estab- patients in dorsal position.
lished, and should lead to the establishment of binding At the points where the cushions
meet, deeper areas are created,
guidelines for all those involved in the treatment and so that risk zones such as shoul-
nursing of the patient. der blades, the bony profile of the
spine, the sacrum, coccyx and
The different positioning techniques require the combined slipping on the positioning aids. With inexpert positioning, heels are positioned almost com-
pletely free.
use of static and dynamic aids. Static aids, such as posi- the unfavourable weight distribution creates shear forces. For the 30 degree oblique posi-
tioning cushions, should be selected under specific criteria. For larger decubitus ulcers, patients with multiple risk fac- tioning (right) the patient is
Their elasticity should be such that it is also preserved tors for pressure ulcer, and postoperatively after decubitus placed on a soft mattress with the
under pressure. If the material bunches together, new surgery, anti-decubitus mattresses of the “low air loss” head well supported by a smaller
pillow. The 30 degree oblique
pressure points result. Especially when using products for type are used to ensure absolutely certain pressure relief. position is created by placing a
free positioning, such as seating rings, superficial pressure long, soft cushion laterally under-
distribution must be assured. There is no point in free posi- A rhythm of two hours is prescribed as the time interval neath the patient’s back.
tioning individual parts of the body and exposing other for repositioning. For patients with a very high decubitus The knees can additionally be
padded with a cushion.
parts to pressure. hazard it may be necessary to reduce this interval further.
A certain amount of experience is generally needed to
The patient must also lie securely and without the risk of position patients correctly according to their requirements.
It is by no means sufficient simply to slide a cushion some-
where underneath the patient. Nursing personnel should
Correct positioning Remarks be fully aware that positioning is not intended to provide
pressure relief in isolated areas, but is a means of influenc-
dorsal position 30 degree all lateral positioning ing the patient’s body feeling as a whole. In the worst
oblique position, left is prohibited case, inadequate positioning can rapidly give rise to
dorsal position 30 degree oblique all lateral positioning considerable further impairments such as respiratory or
position, right is prohibited circulatory problems, stiffening of joints or contractures.
30 degree oblique position, right
30 degree oblique position, left
135 degree positioning
30 degree oblique position, right if absolutely contact-free positioning
30 degree oblique position, left is guaranteed, then also dorsal
contact-free on special cushions position is possible
30 degree oblique position, right sitting prohibited, dorsal
30 degree oblique position, left position is possible if the
135 degree positioning patient is also freely positioned
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 control-
ling 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 microorgan-
isms 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 more effective the cleansing
of the ulcer, the better the quality
The most rapid method of removing necrotic material is of the subsequent granulation tis-
surgical debridement with a scalpel or scissors. Necrotic sue will be. Hydroactive wound
dressings perform valuable service
tissue must be surgically excised as soon as possible, since
in this respect.
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.
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 some-
one “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 oper-
ating 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 fibri-
nous 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 pro-
motes 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 conscien-
tious 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 for-
mation; 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 peri-
wound 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 cul-
ture 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 some-
times 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 antisep-
tic 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 de-
velopment than is the case with antiseptics. Furthermore,
it is difficult to achieve a sufficient active agent concentra-
tion deep inside the wound and to estimate the inhibition
of wound healing processes.
In patients with severe infections, the systemic administra-
tion of antibiotics is indicated, and a microbial determina-
tion 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 granula-
tion tissue, must be produced to fill the defect.
Getting through this phase and supporting the wound in
the best possible manner often presents considerable diffi-
culties in practice because it usually requires much time
and demands absolute consistency in adhering to the
The formation of granulation
therapeutic concept. tissue can only take place in a
homogeneously moist wound
Formation of granulation tissue can only take place if the environment. Promoting and
maintaining this moist wound
following conditions are fulfilled: The ulcer must remain
environment is therefore the most
completely relieved of pressure throughout the entire peri- important task of a wound dress-
od so that blood supply to the wound area remains intact ing in this phase.
and is not impaired by renewed exposure to pressure.
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 disin-
fected, 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 pro-
longed 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 bacteria-
proof 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 demon-
strating 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 ther-
apeutic 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 main-
tained.
Increasing wound contraction and
epithelisation from the wound
However, especially decubitus ulcers tend to epithelise margin due to cell mitosis and
poorly. As Seiler et al. were able to demonstrate in 1989, migration of epithelial cells com-
plete the wound healing process.
epithelial cells in the immediate vicinity of the ulcer margin
A moist wound environment is
show greatly restricted migration. The growth rate was also required in this phase.
only 2-7 %, whereas healthy skin usually showed a growth
rate of about 80 %.
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 trim-
ming 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, conser-
vative 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-effec-
tiveness. 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 suc-
cessful if the patient is optimally prepared for the proce-
dure. Basically, six principles should be followed, and are
always implemented in the same order: Pressure relief,
debridement, wound conditioning, treatment of risk fac-
tors, 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 treat-
ment 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 trans-
posed into the defect, gluteus
maximus fully intact, problem-free
closure of graft site. Flap com-
pletely 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 input-
intensive 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 para-
mount 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 chrono-
logical 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 General factors interfering Local interfering factors
with wound healing Therapeutic options with wound healing Therapeutic options (local findings) Procedure

Infections Diseases Inadequate pressure relief

■ 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
 Therapy of specific underlying
causes, whenever possible, or
optimized treatment
 Use of antibiotics
 Removing of devitalized tissue
(debridement)
 Reduction of fever
 Provision of quality nutrition
 Search for causes of catabolism
 Search for cause of
malnutrition (multifactorial):
e.g. gastric ulcer, depression, zinc
deficiency
 Causal therapy of malnutrition
 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
■ Depression, social isolation  Always treat diseases
■ Anemia optimally, since diseases lead
■ Dehydration to catabolism
■ Diabetes mellitus  Depression: SSRI, care
■ Immune weakness  Hemoglobin > 11 g / dl
■ Heart failure  Drinking volume:
■ Renal failure > 20 ml / kg body weight
■ Diseases of the gastro  Diabetes mellitus: optimal
intestinal tract glucose levels
■ Paralysis  Heart failure, e.g. no leg
■ Immobility edema!
■ Nicotine abuse  White blood count > 2000
(abs.)
 Serum zinc > 12 mmol / L
 Mobilise
Medications
■ Corticosteroids  Always check topical therapeu-
■ Sedative medications tics and medications for nega-
■ Cytostatics tive effects on wound healing
■ Immunosuppressive agents  Sedative medications immo-
■ Toxic topical therapeutic bilise and impede pressure
agents, e.g. hydrogen peroxide 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.
 Optimize pressure relief
 Use only thin, moist dressings
 Debridement
 Optimize pressure relief
 Use only thin, moist dressings
 Systemic antibiotics if infec-
tious parameters elevated
 Debridement
 Keep permanently moist
 Dressing change 4 x daily
 Wound irrigation with Ringer’s
solution
 Keep permanently moist with
suitable hydroactive wound
dressings, e.g. hydrocolloid
dressings
 Check wound preparations for
topical tissue toxicity

(Source Seiler, 2002)

Management of decubitus [40.41]

1) Trochanter decubitus with local
infection with clearly visible red-
dening 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; 1 2
fistulous tracts always indicate
the presence of osteomyelitis
3) Local infection with Candida
albicans (thrush); typical, the red-
dening close to the ulcer edge
4) Whitish, hyperkeratotic lesions
(incipient callus formation) are a
typical sign of insufficient pres-
sure relief on a too firm mattress
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 succes-
sively 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 prevent-
ing 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 diffi-
cult 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 defi-
ciency, the patient’s mental state, depression, social isola-
tion, 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 reli-
ably 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 conflict-
ing 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 stand-
ards 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 meet-
ing, are not a suitable means of providing the legally
required proof of quality of treatment and care.
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 documen-
tation, 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 photo-
graphic records taken at different times.

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. 1 2 3

The records are then always up to date during the course All the images must be durable
of a shift. The occasionally observed practice of collecting and not fade and retain their
all the entries and entering them all at once just before evidential power even after years
if necessary. Thus the careful
ward transfer is to be rejected as inadmissible and impre- administration of files is necessary.
cise. This includes establishment of the
meaningful file designation (thus
A “suitable” choice of language which exactly describes e.g. „Name_Surname_Date.jpg“),
regular backup of all files and,
the state of the wound is of considerable importance for additionally, filing the hardcopy in
the information value of the documentation. In practice, the patient records, if applicable
however, this often causes difficulties and statements are
often imprecise. To eliminate uncertainties in this respect,
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 photo-
graphed 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 treat-
ment 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 conse-
quently 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
Tulle bandaging materials adhere
better cosmetic results. Patients frequently report that their to the wound (above), newly
pain is relieved under moist wound treatment. formed tissue is also detached
when the dressing is changed.
This disruption of wound healing
In addition, the dressing change itself is atraumatic and
can be easily prevented by using
causes less pain because modern dressings, as used for atraumatic wound dressings such
moist wound treatment usually do not stick to the wound, as gel forming calcium alginate
i.e. have atraumatic properties. At the same time, this dressings (below).
“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.
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.
Wound dressings for the moist wound treatment
For practical implementation of the moist therapy is now
the series of hydroactive wound dressings available, by
which can be covered, within the meaning of phase-specif-
ic wound management, the entire scope of the therapeutic
needs.
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 granula-
1
tion 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 super-
absorbent polyacrylate (SAP) as the central component
of its absorbent core. The non-medicated superabsorber is
2
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).
3 At the same time, however, microbially contaminated
The principle of action of wound exudate is absorbed and bound into the absorbent
TenderWet core. This exchange – Ringer’s solution is delivered and
proteins are absorbed – functions because the superab-
sorber 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
ingrowth is possible (3). The moisture and the electrolytes
contained in the Ringer’s solution, such as sodium, potas-
sium 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 cleans-
ing 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 avail-
able in round and rectangular shapes to meet differing
application requirements.
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
TenderWet 24 active is already
be applied immediately. This dispenses with time consum- activated with Ringer’s solution
ing preparations. Another advantage of the already activat- ready for use. The integrated pro-
ed wound pads is that a much greater volume of Ringer’s tective layer makes the dressing
solution can be introduced into the absorbent core than is well suited for treatment under a
compression bandage.
possible with manual impregnation. As a result, the wound
can be kept moist longer.
Hydroactive wound dressings [48.49]
Treatment of a pressure sore on
the heel with TenderWet (Case
study by Antje Wagner, Leinfelden-
Echterdingen): 84-year-old female
patient, coronary heart disease,
arterial occlusive disease, increas-
ing dementia; decubitus on the
left heel. Start of TenderWet treat-
ment on 23 April 99, the necrosis
of the heel extended almost as far
as the bone (Fig. 1). By 22 May
necrotic tissue on the heel had
begun to scale away. The wound
is well supplied with blood; some
granulation tissue had begun to
form (Fig. 2). Consistently contin-
uing this treatment, the heel sore
was completely clean by 11 June
(Fig. 3). Treatment was continued
unaltered until the wound healed
completely (Fig. 4, 14 August).
Packing of a deep decubiti with
gauze strips impregnated with
antiseptics (Fig. 1) does not
always ensure sufficient cleansing,
thus alternatively ensuring of a
quick and thorough debridement
by using of wound pads Tender-
Wet active cavity shall be consid-
ered (documentation of F. Meu-
leneire, Belgium). Preliminary a
palpation by finger is carried out
to determine the size of the
wound cavity, corresponding
marking to the skin surface (Fig.
2) and adjustment of a proper
TenderWet compress size (Fig. 3).
TenderWet active cavity can be
well adjusted due to its´ plasticity
(Fig. 4).
Moreover, the pads are soft and easy to shape, especially
in case of TenderWet active cavity, which can be used to
pack even cavernous wounds without difficulty. In con-
trast, TenderWet 24 active should not be packed into the
wound because of its moisture-repellent protective backing
layer.
1 2 The classical TenderWet must be saturated with Ringer’s
solution before use. How much Ringer’s solution is required
to activate the dressing depends on the size of the com-
press and is indicated on the packing accordingly. For easy
activation of TenderWet (and also of TenderWet 24),
TenderWet solution is supplied in ready to use vials. The
composition of the sterile, pyrogen-free and isotonic solu-
tion corresponds to that of Ringer’s solution.
3 4 TenderWet 24 active and TenderWet 24 are designed so
that the absorbing and rinsing effect is sustained for up to
24 hours. To protect the dressing from strike through, TenderWet 24 active and Tender-
Wet active cavity are already
moisture –repellent layer is integrated inside the dressing
activated with Ringer’s solution
on the side facing away from the wound. The side of the ready for use.
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.
1 2 The following applies generally to all TenderWet wound
dressing 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).
3 4
Hydroactive wound dressings [50.51]
Treatment of a coccyx decubitus
with TenderWet (Case study by
Eduard Rath, Bernried): 84-year-
old 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 dress-
ing 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.
Sorbalgon – calcium alginate dressings
with excellent conformability
Sorbalgon is the wound dressing ideally suited for cleans-
ing and for supporting the build-up of granulation tissue
in superficial and deep infected and non-infected wounds.
By virtue of its excellent packing characteristics, Sorbalgon
also provides effective cleansing and conditioning in deep
1 2
wounds.
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
1
hydrophilic gel which expands and fills out the wound (2).
3 4 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 pro-
vides efficient microbial reduction and helps avoid reconta-
mination. Wounds are swiftly cleansed, and Sorbalgon has
2
therefore proved especially successful in the treatment of
chronic and infected wounds.
Very good wound healing properties of Sorbalgon are
5 6
among the other things due to type of suction properties
of calcium succinate fibres. They absorb 10 ml exudates
3
per gram of weight and thus have very high absorption
capacity. On the other side, the absorption capacity is not The principle of action of
achieved mainly among the fibres as by gauze, but the Sorbalgon
wound fluid penetrates intracapilary into the fibres and the
microbes are safely trapped while transforming the liquid
to gel. With its gel-like consistency, Sorbalgon unlike the
semioclusive wound dressings also acts as a moist dressing
that has regulative effect on exudates and prevents the
wound from drying out.
Hydroactive wound dressings [52.53]
Treatment of a decubitus in the
sacral region, Stage III, with
Sorbalgon (Case study by Fried-
helm Lang, Leonberg): Findings
on admission (Fig. 1), the decubitus
underwent surgical debridement.
A large amount of pus was dis-
charged (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 granu-
lation tissue had formed, the
wound was clean and infection-
free (Fig. 8). With the above
wound status the patient was
transferred back to the nursing
home from where she was
referred.
Sorbalgon has excellent con-
formability qualities and thus also
provides effective cleansing and
conditioning in deeper wounds.
Sorbalgon is available as a
dressing and ribbon.
1 2
Sorbalgon’s gel-forming properties prevent it from sticking
to the wound and dressing changes are painless. However,
complete gelatinisation of the calcium alginate fibres
requires the presence of sufficient exudate. Moistening of
Sorbalgon with Ringer’s solution is advisable when ragged
wounds with low exudation must be packed. Eventually
remaining fibres can be removed from the wound by
3 4 tweezers.
In the wound cleansing phase, 1 to 2 dressing changes
daily may be required depending on the amount of exuda-
tion. Later, as granulation tissue forms, a dressing change
every two to three days may be sufficient. Sorbalgon is
available in three sizes as square dressings. Sorbalgon T is
available in band form.
5 6 Sorbalgon dressings loosely
packed in (left) and their transfor-
mation into a gel-like structure on
contact with exudate (right)
7 8
Hydroactive wound dressings [54.55]
Treatment of decubitus in the
sacral region, Stage III, with
Sorbalgon (Case study by Fried-
helm Lang, Leonberg): Findings
on admission (Fig. 1), the decubi-
tus was treated with a gauze
swab.
After its removal, the necrotic
layer was visible on the sacral
bone (Fig. 2).
10 days after surgical debride-
ment and treatment with Sorbal-
gon, 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.
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
1 2 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-facing side
become progressively smaller in the direction of the outer The hydrophilic foam dressing
coating layer, which produces strong vertical capillary PermaFoam with its convincing
action. The outer PermaFoam layer consists a flexible, physical mode of action extends
the range of treatment options for
3 4 close-porous polyurethane foam and is semipermeable, chronic wounds.
which means bacteria-proof but permeable to water
vapour.
This material combination and design results in product
characteristics which can counteract the maceration prob-
lems 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.
5 6 The large foam pores on the wound side ensure that vis-
cous 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 per-
formed using the foam dressing
PermaFoam, continuous healing
progress was observed.
(7) and (8) Clean granulation
tissue rapidly formed during
PermaFoam treatment. Epithelisa-
tion 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 load-
ing within 65 days.
58
1 2
The absorbed wound exudate then spreads out laterally The therapeutic efficacy of
under the outer layer. In this regard, it is also important PermaFoam derives from its special
pore structure: large pores on the
that PermaFoam has – mainly due to the special pore wound side become progressively
structure – a high retention capacity for fluids. Even when smaller in the direction of the
pressure is applied from outside by, for example, a pressure outer coating layer, which pro-
bandage, the exudate is retained in the foam. Also relevant duces strong vertical capillary
action. As a result, exudate is
3 4 is the fact that the absorbent capacity of PermaFoam is rapidly absorbed deep inside the
only slightly reduced even under the pressure of a com- absorbent pad, but also provides
pression bandage. For example, under a pressure of high retention for reliable fluid
42 mmHg, the absorbent capacity is reduced by only 12 % binding.
compared with the pressure-free condition.
Taken together, all these characteristics result not only in
the desirable rapid regulation of exudation, but also pro-
5 6 tect 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
7 8 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 the wound contours. The dressing is held in place with
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
The principle of action of
Hydrocoll
PermaFoam is soft and flexible and therefore clings well to Hydrocoll is a self-adhesive,
absorbent hydrocolloid dressing
for cleansing and conditioning
elastic dressing retention bandages (e.g. Peha-haft) or over non-infected wounds with
the entire area with adhesive elastic nonwoven fabrics moderate to heavy exudate.
(e.g. Omnifix elastic). The product version PermaFoam For practicable and economical
use, Hydrocoll is available in a
comfort is designed for an easy fixation with an adhesive
variety of shapes and presenta-
border. The used adhesive is gentle on the skin. Perma- tions:
Foam is available in a variety of versions and sizes. (1) and (2) Hydrocoll concave with 1 2
perfect fit for elbows and heels
Hydrocoll – absorbent hydrocolloid dressing (3) and (4) Hydrocoll sacral
specially for wound treatment in
Hydrocoll is a self-adhesive, absorbent hydrocolloid dress- the sacral region
ing for cleansing and conditioning of non-infected wounds
with moderately severely to slighty secretion.
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 3 4
of hydrocolloids capable of absorbing and swelling and
are incorporated in a self-adhesive elastomer. A semi-
permeable film serves to prevent bacterial and moisture Figures (5) – (8) show excerpts
penetration. from the course of wound healing
of a Stage II decubitus with blister-
ing on the left heel. Wound care
The central feature of the mechanism of action of Hydro- was provided with Hydrocoll and
coll is the hydrocolloids incorporated in the backing layer. was uncomplicated. Because of its
On absorbing wound exudate they swell to form a gel high absorbent capacity, Hydrocoll
could be left on the wound for
which expands into the wound and maintains a moist
several days which made treat-
wound environment. The gel remains absorbent until the ment easy and also cost-effective 5 6
hydrocolloids are saturated. During the swelling process because of the reduced number of
the absorbed wound exudate, which is always contaminat- dressing changes.
(case study by Gabi Michl,
ed with detritus, bacteria and their toxins, is securely
Kötzting)
retained within the gel structure.
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 espe-
cially 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 espe-
cially 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 main-
tained 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 epithe-
lial 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.
Hydrocoll is available in different sizes and shapes, e.g.
“concave“ for the treatment of wounds on elbow and heel
or the “sacral“ for the treatment of decubital ulcers in the
sacral region. In the rectangular standard version is also
available for smaller wounds. The “Hydrocoll thin” version
is specially suited for already epithelising wounds.
Hydrotul – hydroactive impregnated dressing
By development of the hydroactive impregnated dressing
Hydrotul, the beneficial properties of traditional ointment
impregnated tulle dressings with the state of the art
hydrocolloid technology have been combined. This opens a
wide field of application for the hydroactive ointment
dressings. Hydrotul is suitable for the treatment of superfi-
cial, both acute and chronic wounds; especially during the
granulation and epithelization. Results of various studies
have implied, that the hydroactive impregnated dressing
Hydrotul promotes the wound healing process particularly
by wounds where the previous therapies failed. The pres-
ence of infection is not contraindicated because unob-
structed exudate drainage is possible.
3) The comb structure of the
bearing matrix prevents from
accumulation of exudate.
2) The Hydrotul ointment
soothes the wound edges.
1) The hydrocolloid particles
keep the wound moist.
Hydroactive wound dressings [62.63]

Sufficient mesh aperture of the
polyamide carrier of Hydrotul (see component, keeps the wound margins soft and supple,
photo above) provides for an
unobstructed drainage of wound
exudate. Application of the
Hydrotul on the burned wound
shows, how Hydrotul keeps the
wound surface moist and supples wound can be always easily assessed. This is important for
(see photo below).
Hydrotul ensures particularly
economic wound management.
The ointment impregnated dress-
ing is a cost-efficient alternative
to other hydroactive products and
is time- and cost-saving due to
prolonged dressing change inter-
vals.
For improved efficiency in wound healing and atraumatic
properties of Hydrotul the hydrocolloid particles incorpo-
rated in polyamide fabric (1) are crucial. These car-
boxymethylcelluose granules absorb the wound exudate
and create the moist wound environment like the known
hydrocolloid dressings, stimulating the wound healing in
all phases. Another benefit of the hydrocolloids is creating
moist environment in the wound base and thus Hydrotul
can remain on the wound for longer time than the conven-
tional wound dressing without risk of drying out.
Additionally, an effect has the impregnation of the carrier
polyamide lattice tulle by hydroactive non-medicated oint-
ment mass based on triglycerides (2). The ointment mass
prevents the dressing from sticking to the wound surface,
enhances the atraumatic properties of the hydrocolloid
thus preventing maceration. Moreover, with the ointment
mass based on triglycerides the adipic component has been
developed, which does not leave any displeasing residues
which could decompose in the wound. Thus state of the
treatment of nearly all wounds, but special importance is
for burns, where reliable wound assessment must be possi-
ble to reveal any changes that may worsen in time. Hydro-
tul should be used on third-degree burns only when
ordered by the attending physician.
Sufficient mesh aperture of the polyamide carrier of Hydro-
tul (3) provides for an unobstructed drainage of the excess
wound exudate to the secondary wound dressing. Hydrotul
can be combined for this purpose with each of current
absorption compresses, like traditional ointment compress-
es. Handling the hydroactive ointment dressing Hydrotul is
unproblematic as well. It can be easily cut to size accord-
ing to wound by using of sterile scissors and prevents from
sticking to the gloves by inspection.
Moreover, it can be documented by previous studies that
by local therapy the ointment dressing, Hydrotul dimin-
ished the continuing pain and by re-dressing the wound
can be easily done without problems and pain. Hydrotul is
available as ointment dressing in the sizes 5 x 5 cm,
10 x 12 cm and 15 x 20 cm sterile and individually sealed.
Hydrosorb – transparent hydrogel dressing
Hydrosorb is particularly suitable for keeping granulation
tissue moist and stimulation of epithelium regeneration
and is thus the optimum wound dressing for phase-adapt-
ed further treatment after wound treatment with Tender-
1
Wet, Sorbalgon or PermaFoam.
Hydrosorb is from the physical viewpoint, a three-dimen-
sional network made of a ready-to-use gel dressing made
of hydrophilic and absorbent polymers where 60% of
water is incorporated. Despite of this high water content, 2
Hydrosorb can absorb additional considerable amounts of The principle of action of
fluid, owing to the presence of hydrophilic groups, without Hydrosorb
losing its gel structure. These properties imply the specific
use of Hydrosorb for the wound treatment: Hydrosorb rep-
resents from the beginning the fully functional, moist com-
press, which does not need, unlike the calcium alginates
or hydrocolloids, any wound exudate for transformation to
gel form. Hydrosorb thereby provides the wound with
moisture for several days from the start (1). At the same
time, Hydrosorb absorbs excessive microbial contaminated
Kapiteltext [64.65]
 secretions which are then held in the gel structure. Then A) Particular macromolecules with
with absorption of exudates the cross links in the polymer their deposited water molecules
create polymer chains through
chains expand, creating space in the macromolecule for special cross links.
the foreign matter like microbes, detritus and odour mole- B) Exudate absorption.
cules from which they cannot leak anymore. This exchange C) The cross links are expanded
ensures the optimum moisture level for wound healing, and create space for secure trap-
ping of microbes, exudates and
thus promoting the production of granulation tissue and odour molecules.
epithelialisation (2). The surface of Hydrosorb is imperme- A B C

able to water and bacteria to protect against secondary

infections.
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.
1 2
3 4
However, it should be noted, that the hyrdogels show
other absorption characteristics than textile materials or
calcium alginates. The hydrogels cannot absorb liquids
spontaneously; their fluid absorption capability occurs only
after certain time period and increases only slowly. But
then the hydrogels like Hydrosorb have the capability of
continuous lasting absorption capacity.
Hydrosorb prevents the dressing from sticking to the
wound and can be removed even after prolonged periods
on the wound without the risk of wound irritation.
Hydrosorb can be removed in its entirety as the gel sheet
structure does not break down because of the absorbed
secretions. No residues remain in the wound and the
condition of the wound can be assessed without prior
irrigation.
In addition, the transparency of Hydrosorb, which is main-
tained even after prolonged use is particularly useful in
practice. It allows inspection of the wound without chang-
ing the dressing.

This ensures the non-disturbance of the wound, very

important for healing, as well as being highly cost-efficient
because of the longer intervals between dressing changes.

Hydroactive wound dressings [66.67]

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.
Hydrosorb Gel is intended for effi-
cient rehydration of dry wounds
and is available in dosing syringes
à 15 g and 8 g.
Hydrosorb is available in two versions as Hydrosorb and
Hydrosorb comfort. Hydrosorb does not have an adhesive
edge and is secured with adhesive tape, a dressing band-
age or a compression bandage. Hydrosorb comfort is
surrounded by a hypoallergenic adhesive film border for
bacteria-proof fixation.
Hydrosorb Gel – for dry wounds rehydration
Hydrosorb Gel is a transparent, viscous and sterile gel
based on carboxymethylcellulose, Ringer’s solution and
glycerine, providing immediately a moist wound environ-
ment helping to promote wound healing to deep and
ragged wounds which are dry or in danger of drying out.
The ingredients of Hydrosorb Gel ensure continuous and
sufficient moisture for dry wounds with the following ther-
apeutic applications: fibrinous and necrotic sloughs are
softened and removed. Hydrosorb Gel thereby absorbs
exudates contaminated by microbes and detritus, where a
small amount of exudate is present. The endogenous phys-
ical debridement is thereby stimulated efficiently and the
physiological secretion necessary for wound healing can
be renewed. In the wound conditioning phase with granu-
lation, the tissue electrolytes build up contained in the
Ringer’s solution like sodium, kalium and calcium promote
cell proliferation.
The dry wounds or wounds in danger of drying out exist
particularly due to the long existing, chronic Ulcera cruris
and decubital ulcers. In second degree burns, the
Hydrosorb Gel cools and soothes pain with its moisture.
Application on infected wounds can be performed only
under the supervision of attending physician.
Hydrosorb Gel is available in convenient dosing syringes of
15 g and 8 g ensuring easy application under all wound
conditions: Through a long discharge, the Hydrosorb Gel
can be applied also to deep, ragged wounds directly and
cleanly. This safe application is promoted by the gel
consistency. The gel is sufficiently packed to prevent imme-
diate escape and soft sufficiently to adapt to the wound
base. The dosing syringe can be easily handled by one
hand, and the gel can be dispensed exactly. Moreover, the
Hydrosorb gel syringe can be effectively emptied unlike
tubes, where gel often remains. An exact amount, neces-
sary for wound treatment, can be dispensed from the
syringe. Clear indication of volume in ml on the syringe is
also advantageous. It enables to determine at a glance,
how much gel has been applied to the wound. The intro-
duced gel quantity can be used to determine the wound
volume and can be recorded in the wound documentation
sheet. After application of von Hydrosorb Gel, the wound
should be covered by an appropriate secondary wound
dressing. Nearly all currently used wound
dressings can be used for
this purpose.
Kapiteltext [68.69]

Silver-containing ointment dress-
ing Atrauman Ag with broad
antimicrobial activity is indicated
for infected wounds or for
wounds compromised by infection.
Atrauman Ag – silver containing ointment dressing
for infection control
For treatment of infected or critically colonised wounds is
indicated the silver containing ointment dressing Atrau-
man Ag with antimicrobial activity. It consists of wide
meshed latice tulle made from polyamide with fibers coat-
ed by elementary silver and additionally impregnated by
an ointment mass. The silver ions are firmly chemically
bonded to the carrier material, resulting in good tolerance
by tissue and only low cellular toxicity. The low toxicity of
Atrauman Ag can be proven in studies on human keratio-
cytes cellular line HaCaT. Thereby is the antimicrobial spec-
trum of Atrauman Ag extraordinary broad and comprises
both Gram positive and Gram negative microbial strains.
The ointment impregnation cares for the wound margins.
Atrauman Ag can be combined e.g. also with hydroactive
wound dressings and foam dressings without losing of
antimicrobial action.
Zetuvit Plus – wound dressing for heavily exuding
wounds
This combined absorption pad has been developed espe-
cially for severely exuding wounds. Due to four layers of
different materials has Zetuvit Plus its excellent useful
properties: The absorbent core made of soft cellulose fluff
is blended with liquid-absorbent polymers (SAP) (1). For
this reason Zetuvit Plus absorbs more than twice that the
traditional absorption pads. The exudate is reliably bond in
the absorbent core, so that Zetuvit Plus can be used also
under pressure, e.g. under compression dressing. However,
binding of the excess exudate also promotes reduction of
the infection risk, because of keeping the microbial con-
taminated exudate away from the wound and reduction of
the risk of recontamination. Moreover, soft texture of the
absorbent core ensures a good padding effect; the wound
is well protected against harmful mechanic influences like
pressure or impact.
The extraordinary effective absorption core is fully enclosed
in a thin non-woven fabric (2) that uniformly distributes
the liquid or exudate in the absorbent core.
The water-repellent but air permeable special non-woven
fabric (3) on the side of the absorbent core facing away
from the wound acts against imbuing of the dressing. The
special non-woven fabric is green, thus the Zetuvit Plus
can be applied safely. The green side shall always face
away from the wound (see photo).
The prinziple of action of Zetuvit
Plus
4
1
3
2
The outer encasement of Zetuvit Plus consisting of two-
layer non-woven fabric (4) has the following functions: The
hydrophobic non-woven outer side prevents sticking to the
wound, which makes the re-dressing more comfortable for
the patient. On the contrary, the hydrophilic cellulose
fibers have a high capillary activity through which exudate
can pass quickly to be retained in the absorbent core.
Thereby the exudate accumulation on the wound is pre- Zetuvit Plus, combined absorption
vented. dressing with SAP for treatment
of severely exuding wounds
Kapiteltext [70.71]
 TenderWet
Products for
hydroactive
wound management
Product characteristics wound pad dressing with super
absorber polyacrylate with unique
absorbing and rinsing effect, acti-
vated before use with the Ringer’s
solution and this is then brought
to the wound and exchanged for
the wound exudate
Properties and main uses due to continuous delivery of
Ringer’s solution and simultaneous
absorption of microbially conta-
minated exudate (= absorbent-
rinsing 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 begin-
ning of the granulation phase
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
excellent conformability, non-medi-
cated, active agent free calcium
alginate dressings that transform
into a moist gel on contact with
wound secretion; the swelling
process also securely traps micro-
organisms in the gel structure
high absorbency with efficient
cleansing action, after transform-
ing into gel keeps the wound
moist, promotes formation of
granulation tissue, due to excel-
lent conformability ideal for
cleansing and conditioning of
deep and cavernous, infected
and non-infected wounds and
after surgical debridement
Sorbalgon, sterile, 5x5, 10x10
and 10x20 cm; Sorbalgon T
ribbons, sterile, 1 g/30 cm and
2 g/30 cm
PermaFoam
hydroactive foam dressing
made of variously structured
foamed material with high ver-
tical wicking effect as well as
high retention for reliable fluid
binding, microbe-proof cover
layer
rapid regulation of wound exu-
dates, protects wound margins
from maceration, particularly
suitable for treatment of venous
ulcers in combination with com-
pression 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
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, PermaFoam
tracheostomy, steril, 8x8 cm
Hydrocoll
self-adhesive hydrocolloid dressing
with particularly absorbent and
swellable hydrocolloids, combined
with semipermeable bacteriaproof
and waterproof cover layer
provides good cleansing, improves
microcirculation in the wound
area, promotes formation of gran-
ulation tissue, no sticking to the
wound, in the gelatinised state
can be removed from the wound
as an entirely intact dressing,
especially suitable for condition-
ing non-infectious wounds with
moderate to slight exudate
Hydrocoll, sterile, 5x5, 7.5x7.5,
10x10, 15x15 and 20x20 cm;
Hydrocoll sacral, sterile,
12x18 cm; Hydrocoll concave,
sterile, 8x12 cm; Hydrocoll
thin, sterile, 5x2.5, 7.5x7.5,
10x10 and 15x15 cm
Hydrotul
hydroactive ointment dressing
with hydrocolloid particles
deposited in open-weave carri-
er polyamide and non-medicat-
ed ointment impregnation
based on triglycerides
provides optimally moist wound
environment for quick healing,
prevents from sticking to the
wound, protect against traumati-
sation by re-dressing, keeps the
wound margins soft and supple,
thus preventing maceration, for
treatment of superficial acute
and chronic wounds in the gran-
ulation- and epitelisation phase
Hydrotul, sterile, 5 x 5 cm, 10 x
12 cm and 15 x 20 cm
Hydroactive wound dressings [72.73]
 Hydrosorb
Products for
hydroactive
wound management
Product characteristics transparent gel made of
absorbent polyurethane poly-
mers with a high integrated
water content of about 60 %,
combined with semipermeable,
bacteriaproof and waterproof
cover layer
Properties and main uses 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
Presentations Hydrosorb, sterile, 5x7.5, 10x10
and 20x20 cm; Hydrosorb
comfort, sterile, 4.5x6.5, 7.5x10,
12.5x12.5 and 21.5x24 cm
Hydrosorb Gel
clear, viscous and sterile hydro-
gel based on carboxymethyl-
cellulose, Ringer’s solution and
glycerine
rehydrates the deep and ragged
wounds which are dry or in dan-
ger of drying out, fibrinous and
necrotic sloughs are softened
and removed, promotes effi-
ciently the autholytical débride-
ment, through electrolytes con-
tained in Ringer’s solution pro-
motes cell proliferation, easy to
use by virtue of dosing syringes
Hydrosorb Gel, sterile, dosing
syringe of 15 g and 8 g
Atrauman Ag
Other products
for wound
treatment
Product characteristics silver-containing ointment dress-
ing with a bactericidal action;
the metallic silver is permanently
bonded to the backing material
made of hydrophobic latice tulle
is additionally impregnated with
non-medicated ointment mass
Properties and main uses for treatment of infected wounds
and wounds endangered by
infection, the broad spectrum of
bactericidal spectrum gramposi-
tive/-negative, long-lasting
bactericidal action, proven good
tissue tolerability and low cyto-
toxicity, the ointment impregna-
tion cares for the wound
margins, shall be applied with
absorbing secondary dressing
Presentations Atrauman Ag, sterile, 5x5,
10x10 and 10x20 cm
Zetuvit Plus
combined absorbent dressing
pad which consists of four layers
of different materials: absorbent
core made of soft cellulose fluff
is blended with super absorbent,
absorbent core is enclosed in
a thin non-woven fabric, water-
repellent special non-woven
fabric and two-layer outer non-
woven fabricwoven fabric
extra highly absorbent, absorbs
more than twice that the tradi-
tional absorption pads die to
super absorbent, the exudate is
reliably bond in the absorbent
core, prevents sticking due to
hydrophobic outer side of non-
woven fabric, good protection
against contamination due to
water-repellent special non-
woven fabric, for treatment of
severely exuding wounds.
Zetuvit Plus, sterile, 10x10,
10x20, 20x25 und 20x40 cm
Hydroactive wound dressings [74.75]
Wound dressings for chronic problem wounds / decubitus ulcers
Wound cleansing
Necrosis
Stage I* and II
TenderWet 24 active
Stage III and IV
TenderWet active cavity
Infection
Exudate ++
■ TenderWet 24 active
■ Sorbalgon
■ Atrauman Ag with
absorbent wound dressing
■ Zetuvit Plus for heavily
exuding wounds; good
padding effect
Exudate +
■ TenderWet 24 active
■ Atrauman Ag with
absorbent wound dressing
■ Hydrosorb Gel
■ Zetuvit Plus with good
padding effect
Exudate ++
■ TenderWet active cavity
■ Sorbalgon/Sorbalgon T
■ Atrauman Ag with
absorbent wound dressing
Exudate +
■ TenderWet active cavity
■ Atrauman Ag with
absorbent wound dressing
Further products
Cosmopor sterile
Granulation Epithelisation Self-adhesive wound dressing
Fibrin layer with high absorbency and good
padding effect for postoperative
wound management and for
sterile treatment of minor injuries
Hydrofilm plus
Self-adhesive, waterproof, trans-
parent film dressing with good
absorbency and padding effect for
postoperative management of
lightly exuding wounds and for
protection against secondary
infections
Dressing retention
Intact peri-wound area Intact peri-wound area Intact peri-wound area Normal skin:
■ PermaFoam comfort ■ PermaFoam comfort ■ Hydrocoll thin Omnifix elastic, Omniplast,
■ PermaFoam sacral ■ PermaFoam sacral ■ Hydrosorb comfort Omnisilk, Peha-haft**, Stülpa-fix
■ PermaFoam concave ■ PermaFoam concave ■ Hydrofilm Sensitive skin:
■ TenderWet 24 active Pre-damaged Pre-damaged Pehalast, Omnipor, Peha-crepp,
Pre-damaged peri-wound area peri-wound area Extremities:
peri-wound area ■ PermaFoam ■ Hydrosorb Peha-haft**, Pehalast, Stülpa-fix
■ PermaFoam Sacral region:
Omnifix elastic, Stülpa-fix,
Molipants (Inco-System)
■ TenderWet 24 active Intact peri-wound area
■ Hydrocoll * Skin protection for Stage I
■ Hydrocoll sacral Hydrocoll thin, Hydrofilm,
■ Hydrocoll concave Menalind professional
Pre-damaged skin protection foam
peri-wound area
■ Hydrosorb **Caution: As a cohesive dressing
retention bandage Peha-haft is to
be used with care in patients with
blood circulation disorders and
■ TenderWet active cavity ■ PermaFoam cavity Intact peri-wound area should not be applied too tightly!
■ PermaFoam cavity ■ Sorbalgon/Sorbalgon T ■ Hydrocoll thin
■ Sorbalgon/Sorbalgon T ■ Hydrosorb comfort
■ Hydrofilm
Pre-damaged
peri-wound area
■ TenderWet active cavity ■ PermaFoam cavity ■ Hydrosorb
Hydroactive wound dressings [76.77]

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 need-
ed. 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 partic-
ularly 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 [78.79]
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 move-
ments 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 par-
ticularly 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 pro-
ducts 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 require-
ments 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 reten-
tion 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 Caution: As a cohesive dressing
apply even on this difficult to dress part of the body and is retention bandage Peha-haft is to
be used with care in patients with
non-slip due to its cohesive coating. If fixation tapes are blood circulation disorders and
required, the skin-friendly surgical adhesive tapes Omni- should not be applied too tightly!
plast, Omnisilk, Omnipor and Omnifilm are outstandingly
suitable for this purpose.
Supplementary aids [80.81]
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 dress-
ing 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
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 protec-
tion products offer a reliable form of care because all the
1 2
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.
3 4 Menalind professional comprises three product lines:
■ Menalind professional cleansing products –
wash lotion, shampoo, skin care bath, skin cleansing
foam, moist skin care tissues and body cleansing wipes
■ Menalind professional care products –
hand cream, skin fluid, skin care oil, body lotion and
oil bath
5 6 ■ Menalind professional –
skin protection foam, skin protection cream, transparent
skin protection cream and skin protection oil spray
7 8
9 10
Supplementary aids [82.83]
The HARTMANN Inco System helps
prevent skin traumatisation
Glossary and list of key terms
Urinary incontinence places great stress on the skin for a
variety of reasons and is thus a risk factor for the causa-
tion of pressure ulcer. Moisture and the aggressive break- A D H
down products of urine irritate and soften the skin. The pH Acute ➞ sudden, rapidly Debridement ➞ 31 Hydroactive wound dressings
becomes increasingly alkaline, the skin becomes increas- occurring onset of the disease ➞ 46 f
Decubitus classification ➞ 18
ingly permeable to water soluble substances, and bacterial Adjuvant ➞ supporting helping, Hydrocoll (hydrocolloid dressing)
Decubitus localisation ➞ 9
contamination increases. An important goal of inconti- e.g. adjuvant therapy ➞ 60
nence care is thus also to prevent this damage to the skin. Decubitus prophylaxis ➞ 70
Affinity ➞ tendency (attraction) Hydrophilic ➞ water-absorbing,
The skin must therefore be kept as dry as possible, which towards someone or something Decubitus risk ➞ 10 f water loving
can only be assured by using high quality incontinence Age of the patient ➞ 14 Defect coverage, plastic surgery Hydrosorb (hydrogel dressing)
products. ➞ 37 ➞ 63
Anamnesis ➞ systematic
questioning (of the patient) Degree of severity, Stage I I
All incontinence products from HARTMANN, through their ➞ 18
Anemia ➞ lack of blood defi- Immobility, elative ➞ 12
material components and product design, offer maximum ciency of red blood corpuscles or Degree of severity, Stage II
Immobility, total ➞ 12
safety: The odour-binding superabsorbent core rapidly blood pigment (haemoglobin) ➞ 18
absorbs liquid and the fluid distribution layer made from Incontinence ➞ 13
Assessment of the patient’s status Degree of severity, Stage III
the special Dry-Plus nonwoven protects against rewetting ➞ 22 f ➞ 18 Inco-System ➞ 76
and keeps the skin drier. Autolysis ➞ ability of dying cells Degree of severity, Stage IV Induced ➞ introduce, instigate
to digest themselves by releasing ➞ 19 med.: cause, trigger
The HARTMANN Inco system includes products for all certain enzymes without the
Documentation ➞ 43 Infection control ➞ 34
involvement of bacteria
degrees of severity of incontinence, with the aim of ensur- Dressing change ➞ 73 Infection prophylaxis ➞ 34
ing patient individualized and economical care under all C
E Insufficient blood supply ➞ 13
conditions: MoliMed for men incontinence pads for men, Cachexia ➞ emaciation due to
MoliMed absorbent pads for slight incontinence, MoliForm severe loss of weight, decay of Epithelisation phase ➞ 37 Irreversible ➞ cannot be
strength resulting from certain changed back, cannot be undone
incontinence pads for slight, moderate, severe and very underlying diseases
Estimation of decubitus risk
severe incontinence, MoliForm for men incontinence pads, ➞ 16 Ischemia ➞ emptiness of blood
Causal ➞ the reason for
MoliCare all-in-one incontinence briefs for severe and very F M
severe incontinence, MoliCare Premium all-in-one inconti- Causes of pressure ulcer ➞ 6 f
Factors interfering with wound Maceration ➞ swelling, soften-
nence briefs with breathable nonwoven fabric layer in the Cleansing phase ➞ 31 healing ➞ 39 f ing e.g. of wound margins
hip region, MoliCare Med all-in-one incontinence briefs Convex ➞ bulging, rounded Fever ➞ 13 Malnutrition ➞ incorrect or
containing an inner top layer of panthenol-treated non- C-reactive protein (CRP) ➞ acute
deficient diet
G
woven fabric and MoliCare Mobile incontinence pants phase protein formed by the liver, Management of pressure ulce ➞
General physical condition ➞ 22
which can be pulled on and off like normal underwear. used as a parameter of inflamma- 20 f
tion Granulation phase ➞ 35
Menalind professional ➞ 75

Glossary and index of key terms [84.85]

Migration ➞ travelling, moving
med.: cell migration
Mitosis ➞ process of cell
division in somatic cells
Multimorbiditiy ➞ simultaneous
presence of several diseases
N Stuttgart/New York, 1997
Nursing activities ➞ 70
Nutritional status ➞ 24
O
Obsolete ➞ out of date, no
longer current no longer comply-
ing 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 mechanical pressure on part of
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 Farhadi; J., Pierer, G.: Plastisch-chirurgische Konzepte
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
the body, diagnostically useful
TenderWet (wound pad with
superabsorber) ➞ 48
Toxic ➞ poisonous
W
Wound dressing ➞ 46 f
Wound treatment ➞ 30 f
References
Bienstein, Ch., Schröder, G., Braun, M., Neander, K.-D.
(Hrsg.): Dekubitus, Deutscher Berufsverband für Pflege-
berufe e.v., Frankfurt/Main, Georg Thieme Verlag,
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 [86.87]
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)
Meuleneire, F. (p. 50)
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