Pressure ulcers (bedsores)

Pressure Sores - (syn. Bed sores, Decubitus ulcer)

Definition

Pressure sores are wounds that occur from tissue breakdown as a result of unrelieved pressure over a particular body site.
Pressure sores typically occur over underlying bony prominences when an individual lies or sits for long periods of time.
The important factor in the development of these sores is unrelieved pressure.
Pressure sores typically occur over the base of the spine, the hip, the heel, the back of the head and back.
Pressure sores may also occur over the bony promiences of the buttocks (ischial tuberosities).

The severity of a pressure sore is graded into four stages:

Stage 1: With these pressure sores, the skin is intact but remains red for more than one hour after release of pressure.

Stage 2: These sores have blistering or ulceration of the skin with or without infection.

Stage 3: These pressure sores have destruction of the skin and underlying fat with tissue loss into the muscle. Infection may be present.

Stage 4: These pressure sores are the most serious and such sores involve the underlying bone or joint; infection may be present.


Incidence / Age

The incidence of pressure sores is highly variable depending upon the population evaluated.
Typical studies suggest that approximately 10% of the general hospital population will have a pressure at any one time.
Pressure sores may affect individuals of any age but they are more common in older patients.

The major factor underlying the development of pressure sores is unrelieved pressure.

In addition shearing forces loss of feeling, incontinence, exposure to moisture, loss of mobility and friction may all contribute to the development of pressure sores.

Individually any one of these factors does not produce a pressure sore but does so in combination with unrelieved pressure.

These patient groups are commonly at risk of developing pressure sores:
1, patients with neurological illnesses;
2, the elderly and
3, the hospitalised.
Pressure sores are associated with medical problems such as heart disease, neurological disease and bone and joint injuries.
Increasing age is an associated factor for pressure sores and in one study over 60% of patients with pressure sores were more than 70 years of age.
Other factors associated with the developments of pressure sores are strokes, being bed or chair bound and impaired nutritional intake.
In addition, patients who are chronically ill and debilitated frequently have nutritional deficiencies.



Dehydration

Dehydration has been shown to produce a two-fold increase in the risk of pressure ulcers.
Individuals with reduced mobility, immobility or sensory impairment are particularly vulnerable.
The National Institute for Clinical Excellence has identified inadequate fluid intake as one of the risk factor in the development of pressure ulcers.
Lack of fluid intake may lead to dehydration resulting in a loss of padding over bony points and hence increased susceptibility to ulcer formation.
Stotts and Hopf found that some nursing home residents with pressure ulcers had low subcutaneous oxygen which could impair ulcer healing.
The results of the pilot study suggested that fluid administration to correct impaired hydration increases levels of tissue oxygen and enhances ulcer healing.


The early sign of a pressure sore is redness of the skin that persists following the release of pressure.
Should the pressure continue, say beyond 2-6 hours, blistering and ulceration of the skin may appear.
Should the pressure continue further death of the underlying fat will occur, typically after about 6 hours of relieved pressure.
At this stage the skin may appear blue and firm to touch.
Full thickness tissue loss with extensive destruction, exposing bone and joints is the next stage and this will develop should pressure relief not be instituted.

Forces such as shear and friction rather than direct pressure may produce the early signs of pressure sore formation.
Prolonged, unrelieved direct pressure typically results in tissue loss with ulcer formation.
These ulcers often demonstrate an iceberg phenomenon. That means the skin wound is only the "tip of the iceberg" and there may be a large associated underlying wound.
The size of the underlying wound is often not appreciated by the patient or their carers.
Pressure sores may smell offensive and may develop serious wound infections.

Complications of disorder:

Chronic wounds such as pressure sores may get infected.
Pressure sores may expose vital internal structures such as joints.



Tests:

Simple blood counts are commonly requested in patients with pressure sores. Such tests are necessary to rule out the presence of anaemia and poor nutritional states.
Other tests may be necessary depending upon associated conditions that the patient may have.

Treatment:

Pressure sores are due to many inter-related factors;
as with many such disease processes - a multidisciplinary approach to treatment is preferred.
Many individuals are involved in the management of patients with pressure sores and this would include the general practitioner, community nurses, dieticians, hospital physicians and reconstructive surgeons.

Medical Treatment

Some pressure sores may heal spontaneously without surgical treatment so long as the wound is thoroughly cleaned and pressure on the area is at worst minimised and at best avoided.
Healing of a pressure sore in these circumstances requires the control of infection and removal of any dead tissue, avoidance of pressure and appropriate wound care.

It is important to determine the underlying course of the pressure and if possible to correct this or minimise its impact.
Appropriate nursing care and the use of pressure releasing mattresses and aids should be used to alleviate pressure.
If moisture is a problem, means to control incontinence or excess sweating should be provided.
Dirty wounds should be cleaned by regular dressing and if necessary by surgical removal of dead tissue.
Some wound dressing products may help the removal of dead tissue.
The patient's nutrition should be looked at and malnourished patients should be given appropriate dietary advice and dietary supplementation where necessary.
High protein diets are helpful and iron supplements may be necessary if the patient is anaemic.
Vitamin supplementation, with vitamin A & C, may occasionally be necessary.

Surgical Treatment

Unfortunately a significant proportion of patients with pressure sores will not respond to non-surgical treatments.
The principle of treatment of a pressure sore is;
1, the pressure sore is cut away back to healthy tissue;
2, underlying bone is partially or completely removed to reduce the bony prominences;
3, the wound is closed with healthy tissue that is durable and can provide good padding over the bony prominence.
This healthy tissue is usually moved from next to the pressure sore and is known as a flap.

Prior to performing surgery for pressure sores it is important that any associated risk factors are dealt with.
These have been detailed above.
In patients with chronic conditions who will remain at risk of pressure sores following any corrective surgery it is important that preventative measures are put in place to prevent the pressure sore from recurring.

Outcome

Patients who develop pressure sores as part of an acute illness, without any chronic component, have a good prognosis for recovery from their pressure sores.
However, many patients are not in this category and most patients who develop pressure sores remain debilitated and at risk following surgery.
Following pressure sore surgery initial cure rates are good (80-90%), However, recurrence following pressure sore surgery is common. The incidence of recurrence is very varied (13-69%).




Questions and Answers
for Non-Clinicians


What is a pressure ulcer? Are they important? What do they look like? Are these different to Bed Sores? Who is likely to develop a pressure ulcer? Are these sores inevitable? What should I do if I think I, or somebody I care for, has a pressure ulcer? How can I prevent a pressure ulcer?


Q What is a pressure ulcer?
A: This is an area of skin damage which is caused by pressure on the body that is not relieved often enough to allow blood to flow normally. This means that oxygen and nutrients do not reach the tissues which cause cells to become damaged. In the worst cases, the tissues actually die.

Q Are they important?
A: YES Very! They are not only painful and debilitating; they can be so severe that they may be fatal! Once they have developed pressure ulcers may also cost a great deal of money to heal and add additional strain to the family budget and to the National Health Service.

Q What do they look like?
A: These areas of skin damage can vary from simple reddened areas to very large, deep sores which may involve damage to the muscles and bones. If you would like to see some pictures click here.

Q Are these different to Bed Sores?

A: No, this is just one of the names used to describe this sort of damage but it is misleading because people who are sitting in chairs are just as likely to develop skin damage if they are unable to move.

Q Who is likely to develop a pressure ulcer?

A: Anybody, young or old, who for some reason is unable to change their position regularly.

For example this may be due to;

conditions which limit movement, either temporarily such as an operation, or longer term such as multiple sclerosis
conditions which alter sensation, such as paralysis
conditions which cause loss of consciousness, such as diabetes, overdose etc
If you or someone you care for has restricted mobility they may be at risk of developing a pressure ulcer

Q Are these ulcers inevitable?
A: NO! These sores can be avoided in nearly every case, though at one time people used to expect them to happen and didn’t question the fact.
There are now very strict protocols in most health settings which are aimed at preventing these ulcers from developing.
This includes assessing the person's risk of developing an ulcer when they are admitted into the care of a nursing/medical professional (including both hospital and community care).
Once assessed, suitable equipment and dressings may be provided to either reduce or eliminate the effects of unrelieved pressure.
Regular reassessment should ensure that the care of the patient remains appropriate as their condition changes over time



Q What should I do if I think I, or somebody I care for, has a pressure ulcer?
A: Don’t be afraid to ask for help and to find out why the ulcer developed in the first place. If you can identify the cause then it is easier to avoid a recurrence.
If the person is an inpatient in a hospital or nursing/residential home, again, ask why the ulcer developed and what is being done to treat the ulcer.
Seek the advice of a nurse or doctor as soon as possible and try to follow the preventative guidelines below.

REMEMBER, SOME ULCERS MAY DEVELOP NO MATTER
HOW CAREFUL YOU ARE,
SO YOU MUST NOT FEEL GUILTY IF THIS HAPPENS TO YOU
OR SOMEONE YOU CARE FOR.
THE IMPORTANT POINT IS
TO SEEK HELP.


Q How can I prevent a pressure ulcer?
A: There are several important factors related to pressure ulcer development and these are listed below;
NOTE: This is a guide only, medical/nursing advice should be sought.

Try to keep mobile and if you cannot then try to change position regularly - probably at least every 2 hours until you can get medical/nursing advice.
This may need to be more frequent if seated as more weight is carried over a smaller surface area enhancing the effects of pressure.

Try to eat a healthy balanced diet and drink plenty of fluids as this has an effect on the condition of the skin.

Try to keep the skin clean and dry.
This is particularly important in the area where incontinence may be a problem.
If incontinence is a problem then please don’t hesitate to discuss this with your nurse as there are some very useful aids to help this problem.
Sometimes the skin may look like it's been damaged by pressure when, in fact, it is urine that has caused soreness.


Check what you are sitting or lying on, is it supporting you well, not too hard and free from wrinkles.
A support surface that either ripples beneath you (special pressure relieving bed) or conforms to your shape will help reduce the effects of pressure.


These are just some very simple tips but REMEMBER there is plenty of help and advice available through your family doctor.