What are the best management strategies for preventing and treating pressure ulcers in geriatric patients or those with limited mobility?

PUSH Index for Pressure Ulcer Assessment

The PUSH (Pressure Ulcer Scale for Healing) index is a validated tool that tracks pressure ulcer healing by scoring three parameters: surface area, exudate amount, and tissue type, with scores ranging from 0 (healed) to 17 (worst possible), though the most critical clinical priority is implementing evidence-based prevention and treatment protocols rather than focusing solely on scoring systems 1.

PUSH Index Components

Surface Area Measurement

• Measure length × width in cm² at each assessment 2
• Score 0 = 0 cm², Score 10 = >24 cm² 2
• Document precise measurements to track healing trajectory 3

Exudate Amount Assessment

• Score 0 = none, 1 = light, 2 = moderate, 3 = heavy 2
• Exudate control requires appropriate dressings (hydrocolloid or foam dressings show equivalent efficacy for complete wound healing) 4

Tissue Type Classification

• Score 0 = closed/epithelialized 2
• Score 1 = epithelial tissue 2
• Score 2 = granulation tissue 2
• Score 3 = slough 2
• Score 4 = necrotic tissue (eschar) 2

Critical Prevention Strategies (Higher Priority Than Scoring)

Risk Assessment Protocol

Perform systematic risk assessment using validated scales (Braden, Norton, or Waterlow) upon admission and reassess regularly based on clinical condition changes 1. All scales demonstrate similar diagnostic accuracy with low sensitivity and specificity, but they remain superior to unstructured clinical judgment for less experienced clinicians 1.

Support Surface Selection

• Use advanced static mattresses or advanced static overlays immediately for all at-risk patients 1, 3
• This represents a strong recommendation with moderate-quality evidence showing lower pressure ulcer risk compared to standard hospital mattresses 1
• Do not use alternating-air mattresses or overlays 1—evidence shows no clear benefit over static surfaces, and they cost significantly more 1

Repositioning Protocol

• Implement systematic repositioning every 2-4 hours around the clock with pressure zone checks at each turn 3
• Standard interval is 2 hours for hemodynamically stable patients on standard mattresses 3
• When using advanced pressure-reducing mattresses, repositioning intervals can be extended to 4 hours without increased ulcer incidence 3
• Use the 30-degree tilt position rather than 90-degree lateral rotation 3—this reduces pressure on bony prominences with a relative risk of 0.62 3
• Avoid flat supine positioning entirely 3

Daily Skin Assessment

• Conduct thorough visual and tactile skin checks of all at-risk areas at least once daily 3
• Focus particularly on sacrum, heels, ischium, and occiput 3
• Document each assessment with time and findings to ensure adherence 3

Treatment Protocol for Existing Ulcers

Wound Assessment Requirements

• Document size, location, eschar and granulation tissue, exudate, odor, sinus tracts, undermining, and infection 2
• Stage appropriately (I through IV) 2
• Measure objectively at each assessment 5

Debridement Indications

• Perform urgent sharp debridement immediately if advancing cellulitis or sepsis occurs 2
• For non-urgent situations, use mechanical, enzymatic, or autolytic debridement methods 2
• All necrotic tissue requires removal prior to further treatment 6

Wound Cleansing and Dressings

• Clean with normal saline or water to remove debris 4, 2
• Avoid harsh antiseptics that damage healing tissue 4
• Apply hydrocolloid dressings as primary treatment for Stage II blistered ulcers 4—they are superior to gauze for reducing wound size 4
• Hydrocolloid or foam dressings are equivalent for complete wound healing 4

Infection Management

• Manage bacterial load with cleansing 2
• Consider topical antibiotics only if no improvement in healing after 14 days 2
• Reserve systemic antibiotics for advancing cellulitis, osteomyelitis, or systemic infection 4, 2
• Rule out osteomyelitis in all full-thickness pressure ulcers 6

Nutritional Support

• Provide protein supplementation for patients with nutritional deficiencies 3, 4
• Malnutrition significantly impairs wound healing and increases ulcer risk 3
• Avoid vitamin C supplementation alone as it shows no benefit over placebo 4

Implementation Framework

Multicomponent Prevention Program

Establish a bundled approach that includes 1, 3:

• Simplification and standardization of pressure ulcer interventions and documentation 1, 3
• Multidisciplinary team involvement with designated leadership 1, 3
• Designated "skin champions" to educate personnel 1, 3
• Ongoing staff education 1, 3
• Sustained audit and feedback 1, 3

This bundled approach demonstrates cost savings of approximately $11.5 million annually in hospital systems while significantly reducing pressure ulcer prevalence 3.

Critical Pitfalls to Avoid

• Do not delay repositioning for hemodynamically stable patients—vasopressor use is not a contraindication to position changes 3
• Do not use dressings with antimicrobial agents solely to accelerate healing 4—this represents a strong recommendation despite low-quality evidence 4
• Do not rely on PUSH scoring alone without implementing comprehensive prevention protocols—the development of a pressure ulcer is associated with nearly twice the mortality risk 5
• Do not wait for ulcer progression—if treated with comprehensive regimen upon early recognition, nearly all stage IV ulcers can be avoided 5