Wound Management

William R. Mikesell, PharmD

PGY1 Pharmacy Resident
Lutheran Hospital
About Me:
Objectives:
• Recognize causes of pressure ulcers
• Describe the impact of pressure ulcers on
patients
• Identify treatment options for patients with
pressure ulcers
• Identify preventative measures for patients
• Evaluate proper therapy for patient scenarios.
Epidemiology:
• Common in hospital and facilities.
• Incidence by setting varies widely, but 2.5 million
treated in the US alone each year
• Affects reimbursements, since easily preventable yet
devastating if they do happen (especially in frail older
adults, don’t heal chronic wounds, eventual systemic
infection, etc).
• LOTS of pain and 100% preventable.
What Causes a Pressure Ulcer?
• A pressure ulcer is damage to the skin and
underlying tissue due to intense or prolonged
pressure over an area of the body where bone is
located
• Prolonged pressure and compression blocks blood
flow → cell death and wounds
• Shearing forces = gravity effects on friction –
tearing, trauma to blood vessels and lymphatic
system.
Common Area(s)
Most commonly occurs over areas around
the sacrum and coccyx (tail bone)
Other areas can include:
• Elbow
• Scapula
• Heels
• Back of the head
Relevance
• Pressure ulcers can be minor
• If left untreated, the wound can progress deeper
into the skin and soft tissue
• Can result into osteomyelitis (bone infection) or
sepsis
• Prolonged Hospital stay
• Painful to the patient
Risk Factors:
• Elderly
• Thinning skin
• Decrease in adipose
• Bed-bound individuals
• Prolonged immobility
• Patient restraints
• Patients with poor nutrition
• Patients with impaired sensations
• Spinal cord injury
• Neuropathy
• Type II Diabetes
• Vascular diseases
• Stroke
• Smoking
• Immunosuppression
Symptoms:
• Pain or soreness over the area
• Red/purple discoloration of the skin
• Open wound
Diagnosis:
Once a pressure ulcer is identified, staging and careful
documentation of the wound size should be performed.
Staging:
Stage Characteristics

I Nonblanchable erythema
Skin intact

II Possible blister formation

Partial-thickness skin damage

III Subcutaneous fat exposed

Full-thickness skin loss

IV Exposed muscles, bones, tendons, or vital organs

Skin, subcutaneous and possibly more tissue loss

Unstageable Entire wound base covered by slough and/or eschar

Full-thickness skin loss

Deep Tissue Injury Unknown level of tissue injured below skin

Skin intact
Prevention:
Pressure Redistribution:
• Position and Inclination
• Place pillows and wedges or protectors under high risk areas or near
them to relieve pressure
• Don’t incline head of the bed over 30 degrees
• Repositioning (timed turning)
• Supine: every 2 hrs. back, one side, other side, repeat
• Chairs: every 1 hr. tilt, elevate, shift weight
• Done carefully to avoid friction and shear
• Improve mobility
• Improve skin condition
• This may include prompt treatment of hypotension, limiting
vasoconstrictive agents,
• improving cardiac contractility, or revascularization for some patients
with severe
• peripheral artery disease
• Proper skin care
• Assess and keep clean and dry but not too dry (high fatty acid lotion,
healthy skin)
Treatment: Overview
Treatment: Pain Control
Pain assessments should be completed regularly:
• Repositioning
• Dressing changes
• Debridement
Goal: Eliminate pain by:
• Covering the wound
• Adjusting pressure-reducing surfaces
• Repositioning
• Providing topical or systemic analgesia
Treatment:
1. Remove pressure from the area to restore blood flow
a. Repositioning the patient
b. Limit time spent in the bed or chair
c. Using a mattress that provides pressure distribution
d. Waffle seat cushion
e. Provide elevation if necessary
Treatment: Continued
Bedridden Patients:
• Strict adherence to repositioning the patient regularly.
• Any methods to pad the area of the pressure ulcer
should be instituted if not already in use.
Patients with prosthetics or wheelchairs
• Refitting
• May need to go without them to allow healing
Wound Management:
Consult:
Minor wounds:
• Clean the wound with normal saline
• Keep covered with protective dressing

Deep wounds or wounds with signs of infection:

• Antibiotics
• Surgical debridement
• Wound Vac
Dressing and Topical Agents:
Dressings should be chosen depending on the
wound being treated.
Things to consider:
• Size, depth, shape and location of the wound
• Presence and volume of exudate
• Presence of tunneling and tissue undermining
• Type of tissue in the wound bed and surrounding skin
condition
Types of Dressings:
Gauze dressings:
• The traditional wet-to-dry method of gauze dressing now has more
limited use in the treatment of pressure ulcers.
• Helps maintain a moist environment
Alginate dressings:
• Very absorbent material
• Ideal for wounds with moderate to high discharge
Foam dressings:
• Foam dressings are often used for prevention of pressure ulcers
because they provide some cushion.
Hydrocolloid dressings:
• Well suited for wounds that have minimal to moderate drainage
and are often used on Stage II and Stage III pressure ulcers.
Types of Dressings:
Hydrogel dressings:
• Hydrogel dressings are gel based and are 90% water.
• Ideally used in dry or dehydrated wounds and are often used over
granulation tissue
Silver-containing dressings:
• Silver has bactericidal properties and dressings that are
impregnated with silver
• Ideal for use in infected wounds
Honey-containing dressings:
• Low evidence for use
Transparent film dressings:
• Used primarily to protect Stage I or II ulcers where the skin remains
intact.
• They provide a barrier to urine, stool, and other bodily fluids, which
can macerate the skin.
• Because they are transparent, allow observation
What Stage is this Pressure Ulcer?

What type of dressing should be used?

What Stage is this Pressure Ulcer?

What type of dressing should be used?

What Stage is this Pressure Ulcer?
What type of dressing should be used?
What Stage is this Pressure Ulcer?

What type of dressing should be used?

Infection Control:
Some surgeons elect to treat the wound initially with
locally applied antiseptics:
• Povidone iodine
• Silver sulfadiazine
• Hydrogen peroxide
• Dakin’s Solution (sodium hypochlorite)
These solutions should only be used short term
• They can slow the healing process through their
cytotoxic effects
Antibiotics:
When to use IV antibiotics:
• Should only be used in patients with significant cellulitis,
systemic signs and symptoms of infection, or evidence
of osteomyelitis
• A clean pressure ulcer, even with some necrotic debris,
does not require IV antibiotics
Common bacteria:
• Staphylococcus
• Proteus
• Streptococcus
• Pseudomonas
• Escherichia
• Enterococcus
Patient Case:
HR is a 74 year old male who developed a pressure ulcer on his
foot. The area is red and painful for the patient. While rounding
the prescriber ask you if we should start antibiotics?

What information do we need?

• Pressure Ulcer Stage
• WBC
• 21 × 109/L
• Temperature
• 98 F
• Pus formation, red streaking, swelling
• MRSA PCR
• Negative
• Pain Score
Patient Case:
HR’s shows evidence of osteomyelitis and the
wound culture results in streptococcus group B.

Which of the following is an appropriate regimen?

A. Levofloxacin 750 mg daily
B. Ceftriaxone 2 g daily
C. Meropenem 500 mg Q8H
D. Cefepime 2 g Q12H
Nutrition:
Protein Intake:
• Without sufficient nutrition and protein intake, the
wound will have trouble healing
• If compatible, achieve a positive nitrogen balance
• 30 - 35 Kcal/kg/day
• 1.25 - 1.5 g of protein/kg/day
• Consider Vitamin C, and
Zinc supplements
Summary and Tips:
• Use the objectives as a guide
• Recognize prevention and treatment options for patients
• When given a patient case be able to determine when
different therapies/management are warranted
References
1. Boyko TV, Longaker MT, Yang GP. Review of the Current Management of
Pressure Ulcers. Adv Wound Care (New Rochelle). 2018 Feb 1;7(2):57-67.
doi: 10.1089/wound.2016.0697. PMID: 29392094; PMCID: PMC5792240.
2. Dana AN, Bauman WA. Bacteriology of pressure ulcers in individuals with
spinal cord injury: What we know and what we should know. J Spinal Cord
Med. 2015 Mar;38(2):147-60. doi: 10.1179/2045772314Y.0000000234. Epub
2014 Aug 17. PMID: 25130374; PMCID: PMC4397196.
3. Multiple Entries. Lexi-Drugs. Lexi-Comp Online. Lexicomp, Inc. Hudson, OH.
Available at: http://online.lexi.com/crlonline. Accessed March, 10th, 2023
Contact:
Email:
william_mikesell1@lhn.net

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