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Pressure ulcers are areas of tissue damage that develop when the skin and soft tissues (eg, muscle) are squeezed between the bones and the surface that is in contact with the body, such as a mattress. Common areas for pressure ulcers to develop include the hip, heel, buttocks, and other areas where the bone underneath is close to the body surface (Figure: Common Locations of Pressure Ulcers). Pressure ulcers are sometimes called decubitus ulcers or bed sores, but pressure ulcer is the best term because pressure is the main cause of the problem. Pressure ulcers are a serious and common problem of older adults, affecting approximately one million Americans (primarily those over 65 years old). The occurrence of pressure ulcers varies greatly, depending on the healthcare setting. Pressure ulcers develop in up to one-sixth of older adults receiving home care, in up to one-third of older adults in hospitals and nursing homes, and even more often in intensive-care units. The frequency of pressure ulcers can be used as a marker of the quality of care in long-term-care settings. More ulcers usually means poorer care; however, it is important to remember that usually the sickest patients are the ones who get ulcers, so in a facility that doesn’t accept these sick patients, the number of ulcers may be few, but the care may still not be the best.
Three processes are involved in the development of pressure ulcers. The main one is the pressure that body weight puts on tissues as they become squeezed between bones and a surface. Friction created by the body sliding over sheets, upholstery, etc also plays a part in irritating the skin. Poor circulation of blood to the area, too much moisture, and poor skin quality can also contribute to the problem. The ulcer comes about when the pressure cuts off the blood supply to an area of tissues, and those tissues then die and slough off. What Do Pressure Ulcers Look Like? Depending on how large and how severe the ulcers are, they can appear as red areas, "craters," blisters, or large, dark scabs. Ulcers are classified into clinical stages, depending on appearance:
Who Gets Pressure Ulcers? The main risk factor for pressure ulcers is not being able to move around, or immobility. Any illness that results in immobility or having to stay in bed for a long time (eg, stroke, surgery, cancer, heart failure, pneumonia, etc) increases the risk of pressure ulcers. Other illnesses that increase risk include dry skin, diabetes, anemia, dementia, renal failure, and various infections. Urinary and fecal incontinence (ie, soiling oneself) are also associated with ulcers, because of the moisture and bacteria on the skin. Old age is a risk factor because older adults have an increased risk of debilitating illness, have changes in their skin that make it thinner and more fragile, and have less spontaneous movements during sleep. Lifestyle factors associated with pressure ulcers include lack of physical activity, smoking, and poor nutrition. Complications Pressure ulcers can have serious and even life-threatening complications. The most serious complication is blood poisoning (septicemia). Other types of infections are also common, including local infections, skin infections, and bone infections. For about 25% of people with nonhealing pressure ulcers, the underlying bone is involved in the infection. Pressure ulcers can also serve as sources of serious infections by bacteria that are resistant to normal antibiotics. Other complications include pain and depression, both of which have been linked to slow wound healing. Finally, because most pressure ulcers, particularly deep ones, take a long time and a lot of care to heal, pressure ulcers can have a significant impact on the quality of life of older people who often need nursing care or may need to be in a specialized facility for treatment. Prevention The best way to deal with pressure ulcers is to prevent them before they start. Movement and position Maintaining or improving the ability to move around is one of the most effective ways to minimize the risk of developing pressure ulcers. People who are not confined to bed should be encouraged to move from bed to chair and to stand and walk. Attention to posture, balance, and weight distribution (eg, shifting weight every 15 minutes) can help people when sitting. People who are bedbound can still benefit from various exercises that put their joints through a range of motion. Bedbound people should be repositioned frequently to relieve pressure over bony areas. How often someone should be repositioned depends on the person’s health and the quality of the supporting surface (eg, some beds are designed to decrease the pressure on bony areas of the body). Older adults at risk of developing pressure ulcers should be repositioned at least every 2 hours. People who are likely to develop pressure ulcers should be repositioned often, changing from the back to their right side and then to their left side, keeping the back at a 30° angle to the bed surface. This avoids direct pressure on the bony areas of the lower back, hips, heels, and ankles–the sites where 80% of all pressure ulcers develop. Pressure and friction Pillows placed between the legs, behind the back, and supporting each arm can help maintain good position. "Doughnuts" should not be used as seating cushions because they increase pressure over the area of contact and may actually cause pressure ulcers. Friction can be minimized by using proper repositioning, transferring, and turning techniques. Using lubricants (eg, cornstarch and creams), protective films (eg, transparent film dressings and skin sealants), protective dressings, and protective padding can also help. Bed-positioning devices such as pillows or foam wedges should be used to keep bony areas from being in direct contact with one another. The head of the bed should be elevated as little as possible, keeping in mind other medical conditions the person may have. Lifting devices, such as trapezes or bed linen, can be used to move the person in bed, rather than tugging directly on skin or sliding along the skin. Skin care All older adults at risk of pressure ulcers should have a thorough skin inspection every day, with particular attention to all bony areas. The skin should be washed with warm water and a mild cleansing agent to minimize irritation and dryness. Every effort should be made to avoid low humidity (less than 40%) and exposure to cold. These environmental factors lead to dry skin, which can be damaged more easily. Dry skin should be treated with moisturizers. Bony areas should not be massaged, because this can cause tissue damage. The skin should also be protected from excessive dampness caused by sweat, wound drainage, and urinary or fecal incontinence. Moisturizers and moisture barriers can be used to protect the skin. Disposable underpads to control moisture and perspiration can help draw moisture away from skin. However, disposable briefs to manage incontinence should be checked and changed frequently to prevent skin irritation and infection that can develop quickly. Supporting surfaces Older adults at risk of developing pressure ulcers may benefit from a mattress, pad, or other supporting surface that is designed to relieve pressure. These materials vary in cost and technical complexity, from simple foam pads; to cushions filled with gel, fluid, or air; to other more technically complex devices. However, even relatively simple cushions often help prevent pressure ulcers. Your healthcare providers can advise you on the types of supporting surfaces that will fit your needs and budget. While these devices can help relieve pressure, they do not eliminate it entirely and are not a substitute for shifting position periodically to more completely relieve pressure from certain areas. Nutrition Poor nutrition had been associated with development of pressure ulcers. A good diet is important and should include adequate fluids, protein, vitamins, and minerals (see also Nutrition). Protection of the heel The heel is especially vulnerable to pressure ulcers because it has so little soft tissue between the bone and the skin to absorb pressure. Specific methods to prevent heel ulcers include the following:
Treatment A pressure ulcer will not heal unless underlying causes are identified and effectively managed. Whenever pressure ulcers develop, they should be examined by your healthcare provider. The size, number, location, and depth of pressure ulcers should be recorded. Any evidence of infection (eg, a milky drainage, fever, foul odor, or surrounding redness of the skin) should be noted. Your healthcare providers may gently push around the edge of the ulcer and probe it with a clean cotton swab to determine how deep it is. Blood tests or X-rays may also be needed to gauge infection or involvement of underlying bone. Any underlying health conditions or barriers that prevent someone from being able to move around should be corrected or managed. Preventive measures (eg, frequent and appropriate repositioning, control of dampness, proper diet, etc) should be reviewed to limit recurrence. Specific treatments to promote healing Sometimes, specific treatments are needed to encourage and speed the healing of pressure ulcers. For example, dead tissue can support infection and prevent healing, so it needs to be removed through a process called debridement. Debridement can be done by cutting away the dead tissue, by mechanically removing it through scrubbing or irrigation, or by dissolving it with enzyme preparations. Your healthcare provider will select a debridement method based on your health condition, and on the condition of the ulcer and whether it is infected. Various types of dressings are used to absorb drainage and promote the healing of pressure ulcers. Wound cleansing and dressing changes are two of the most important methods for minimizing infection. Cleansing the wound and changing the dressing more often is particularly important if there is pus or foul-smelling drainage (ie, infection) in the area. People handling any infected material from the pressure ulcer should wear gloves, so that the germs are not spread from the ulcer to other areas. If the pressure ulcer is severe, surgical repair may be needed. However, surgically treated ulcers tend to recur, especially if underlying problems are not corrected. Antibacterial drugs Antibacterial drugs may be needed if the ulcer is not healing or it continues to ooze after 2 weeks of proper cleansing and bandage changes. Some antibacterial preparations can be applied directly to the skin (eg, silver sulfadiazine and mupirocin ointment) up to three times a day for 1—2 weeks, as long as there is no allergic reaction. Stronger antiseptics (eg, iodine, hydrogen peroxide, and bleach) are not recommended for long-term use, because they can cause damage the tissue and delay healing. Antibiotics (given by mouth or injected) are needed for people who have blood poisoning or infections in the skin or underlying bone. Antibiotics are also given to prevent diseased heart valves from getting infected, or when the ulcer needs surgical repair. New treatments under investigation Over the years, many treatments have been tried to heal pressure ulcers, including hyperbaric oxygen, laser irradiation, and ultrasound. However, scientific data to support these treatments are often lacking. Newer techniques to stimulate wound healing show promise. These include the use of growth factors, electrical stimulation, vacuum-assisted closure, and heat therapy. Monitoring healing Your healthcare provider will monitor the healing process of any pressure ulcers to gauge the effectiveness of treatment. Usually, the depth and width of the ulcers are measured, either with rulers or tracing paper, or with newer specialized tools. Ultrasound can also be used to obtain three-dimensional images of the ulcer. Healing progress is usually evaluated weekly. Depending on the size and severity of the ulcers, healing may take from only a few days to several months. Especially severe pressure ulcers may take up to a year to heal, and unfortunately, some may never heal, especially when the person has other illnesses. There are no specific guidelines that can be used to predict whether an ulcer will be "nonhealing." |
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Published: 3/17/2005