Pressure Ulcer Stage 2

Stage 2 pressure ulcer is partial thickness skin loss with exposed dermis, presenting as a shallow open ulcer with a red pink wound bed without slough, or an intact or ruptured serum filled blister. Adipose tissue, bone and muscle are not exposed.

• Often caused by shear and friction over the sacrum and heels, or by moisture damage that is misclassified.
• Healing is expected within 1 to 3 weeks when pressure is removed.

Shallow, painful, moist, pink or red ulcer or blister, with defined edges and no necrosis or slough.

• Surrounding skin may be erythematous or macerated.
• Differential diagnosis: moisture associated skin damage, incontinence dermatitis, skin tear, friction blister, herpes zoster, bullous pemphigoid, burn, epidermolysis bullosa, impetigo, candidiasis, contact dermatitis.
• Complications: infection, deepening to stage 3 or 4, pain, delayed healing, cellulitis, sepsis.

Clinical.

• Measure length, width and depth, document wound bed, exudate, edge and surrounding skin, and photograph.
• Wound swab only when clinical infection is present (increasing pain, warmth, pus, odour, spreading erythema).
• Nutrition assessment, glucose and albumin; full blood count and CRP if systemic signs.

Moist wound healing with complete pressure relief.

• Supportive: offload completely, 30 degree side lying position and repositioning every 2 hours, pressure redistribution mattress, heel suspension, manage incontinence and moisture, avoid shear when moving, nutrition (protein 1.25 to 1.5 g/kg/day, energy 30 to 35 kcal/kg/day), hydration.
• Pharmacological: cleanse with normal saline at each dressing; paracetamol 1 g 30 to 60 minutes before dressing changes; topical lidocaine 2 percent gel if painful; barrier film to periwound skin. Antibiotics only for clinical infection: flucloxacillin 500 mg four times daily for 7 days or amoxicillin clavulanate 625 mg three times daily for 7 days. Silver or iodine based dressings for local critical colonisation, for short periods.
• Procedures: hydrocolloid or soft silicone foam dressing left in place for 3 to 7 days; leave intact blisters undisturbed under protective dressing; aspirate a tense blister under aseptic technique but leave the roof in place; gentle cleansing without scrubbing.
• Special groups: spinal cord injury, specialist seating and pressure mapping; elderly, treat malnutrition and dehydration; diabetes, optimise glycaemia and examine feet; paediatrics, protect device sites.
• Red flags: deepening wound, slough or necrosis, undermining, increasing exudate or odour, fever, exposed fat or bone, no improvement within 2 weeks.
• Follow-up: weekly measurement; reassess the whole care plan if not healing in 2 weeks; refer to a wound care specialist for deterioration.