The terms pressure sore and decubitus ulcer are used interchangeably to describe a localized area of tissue injury that develops when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time. A pressure sore can range in severity from a mild discoloration of the skin to a very deep wound extending to underlying organs and bone.
Prolonged compression of tissues with an external surface can cause injury due to restricted blood flow. This in turn leads to necrosis (cell death) and ulceration of the tissue. The external surfaces commonly found in these cases include mattresses, chairs, wheelchairs, or other parts of the body. Pressure sores may also occur due to forces of friction and shearing. Friction injuries occur when the skin frequently moves across a coarse surface such as sliding against bed sheets. Environmental conditions such as low humidity and exposure to cold also may be contributing factors. In persons who have full mobility and respond to pressure-related discomfort, pressure sores typically do not occur because of frequent alterations in body position.
Pressure sores are prevented when proper care and supports are consistently provided.
There are a number of clearly identified risk factors that put consumers at higher risk for developing pressure sores. The most common risk factors for an individual include the following:
- Lack of physical activity: Extended periods of time are routinely spent lying in bed or sitting in a chair.
- Lack of mobility: Inability to make frequent changes or shifts in body position without assistance from others.
- Poor nutrition: Inadequate dietary and fluid intake or poor nutritional status related to other conditions (e.g., anemia).
- Exposure to moisture: Skin is frequently exposed to moisture from perspiration, urine, wound drainage, etc.
- Limitations in perception of discomfort: Any limitation in perceiving or responding to stimuli related to physical discomfort or pain.
- Friction and shear: Skin is exposed to friction and shear forces due to frequent sliding against support surfaces, improper positioning and transfer techniques.
Classification of Pressure Sores
Pressure sores most commonly occur over bony prominences, especially along the hips, buttocks, and lower extremities. Pressure sores are graded or staged to classify the degree of tissue damage observed. Pressure sores can be deceiving to an inexperienced observer as the tissue damage may be much more extensive than is readily apparent. The most widely accepted classification system is that adopted by the National Pressure Ulcer Advisory Panel. The stages identified in this system can be summarized as follows:
- Stage I: Non-blanchable erythema of intact skin. In consumers with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators.
- Stage II: Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents as an abrasion, blister, or shallow crater.
- Stage III: Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
- Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (for example, tendon or joint capsule).
It is important to note that not all pressure sores follow a standard progression from Stage I to Stage IV and not all healing processes follow a standard regression.
Effective prevention requires diligent care and support. To prevent pressure ulcers, consumers at risk must be identified so that risk factors can be mitigated through planning and intervention. The primary risk factors for pressure sores are immobility and limited activity levels. The Braden Scale is often used for systematic risk assessment when these primary risk factors are present. An individualized plan of care for persons at risk is usually necessary. Caregivers and others providing services and supports often need guidance and training to sufficiently address these specific needs.
Common prevention strategies for persons at risk include the following:
- Routinely check for skin changes. Skin areas covering bony prominences should be especially noted. Any signs of reddened areas that remain after the pressure is relieved should be closely monitored. Early recognition of changes in skin integrity is critical.
- Maintain clean and dry skin. Skin should be cleaned whenever soiled and care should be used to minimize force and friction during cleaning. To minimize irritation and prevent dry skin, warm (instead of hot) water is used along with mild soap and lubricating lotions. Moisture from urine, stool, and perspiration should be minimized through pads or briefs that have quick drying surfaces. Clothing and bed linen should be kept clean and dry.
- Frequently reposition. Supports should be provided as needed to assist the person in repositioning or changing body position with a frequency that assures that pressure is adequately relieved. Postural alignment, distribution of weight, balance and stability, and pressure relief should be considered when positioning persons in chairs or wheelchairs. A written positioning plan and schedule should be used.
- Use appropriate support devices. Depending upon individual circumstances, pressure-relieving devices for support surfaces can be used (foam, gel or air cushions, pads, special mattresses). Positioning devices (foam wedges or bolsters) may also be used.
- Use appropriate lifting and transfer techniques. To protect the skin from injury caused by shear and friction, appropriate lifting and transfer techniques and devices should be used. Care must be taken to minimize any sliding or rubbing of the skin against surfaces.
Maintain adequate nutrition and hydration. Supplements and supports may be needed to achieve adequate nutrition levels to maintain skin integrity.
Basic Treatment Strategies
Timely intervention is critical to prevent further progression of tissue damage. Collaboration among clinical professionals is necessary to design the most effective approaches. Treatment of pressure sores involves:
- Reducing or eliminating the cause of the pressure. Frequent and proper positioning for alignment, distribution of weight, and relief of pressure is the cornerstone of treatment, as well as prevention. To the extent possible, pressure over the wound area should be minimized or eliminated. Generally, repositioning should occur at least every two hours and a shorter interval may be necessary for some consumers. Persons sitting in chairs or wheelchairs may need to shift the points under pressure every hour. Positioning devices may be necessary to protect bony prominences and prevent shearing forces that may result from sliding down in a chair or elevated bed. Pressure-reducing devices for support surfaces may also be indicated.
- Caring for the wound. The wound and surrounding skin must be kept clean and dry. Frequent cleansing of the area is necessary and bacterial contamination should be assessed and treated expeditiously. Infections are treated with antibiotics as indicated. Removal or debridement of necrotic tissue may be necessary and extensive wounds may require surgical intervention. Wound dressings will vary with the stage of the wound.
- Optimizing nutritional status. Overall nutritional status should be evaluated and optimized to facilitate wound healing. Dietary supplements may be necessary.
- Close monitoring. Healing pressure sores should be assessed regularly to ensure continued progress toward the goal of complete healing. The person's general health, nutritional adequacy, and pain level must be monitored as well as signs of complications such as advancing cellulitis, abscess or sepsis.
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