GuidelinesPrimary Care STG
Pressure Ulcers/ Sores
Pressure Ulcers/Sores
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ICD 10 code: L89.0-3/L89.9
DESCRIPTION
- Localised damage to the skin and underlying tissue that usually occurs over bony prominences as a result of pressure, or pressure in combination with shear force and/or friction
- The most common sites are the skin overlying the sacrum, coccyx, heels, and hips, but other sites can also be affected
- Pressure ulcers most commonly develop in individuals who are immobile, including those bedridden or confined to a wheelchair
- Other factors increasing the risk of pressure ulcer development are:
- Skin wetness e.g. incontinence
- Reduced blood flow e.g. arteriosclerosis
- Reduced skin sensation e.g. paralysis or neuropathy
GENERAL MEASURES
Skin care
- The skin should be kept clean and dry. Ensure that the skin folds are dried thoroughly
Wound odour
- Regular cleansing, debridement and management of infection
- Activated charcoal dressings may be used
Pressure redistribution
- Repositioning and turning at regular intervals, every 2-4 hours. Individual receiving palliative care should be repositioned in accordance with the individual’s wishes, comfort and tolerance
- Avoid positioning the individual on the wound if erythema is present
MEDICINE TREATMENT
Cleanse the skin prior to application of a barrier product.
- Zinc and castor oil, topical ointment
LoE:IIIb37
For pain
- See: Pain
REFERRAL
- Patients with pressure sores or those at high risk of development of pressure sores to rehabilitation services, if available
LoE:IIb38
Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-2024_Version 1.0_07 November 2024
Chapter 5: Skin Conditions_5.19 Pressure Ulcers/ Sores