Pressure Sores

Definition

Pressure sores are also known as Bed sores, and by the medical term (Latin) as decubitus. They are ulcers, or sores, that develop on areas of the body that have endured sustained stress or pressure for long periods of time, such as suffered by people in wheelchairs or confined to bed rest. Such sores indicate what is known as deep tissue, injury and can be a sign of more serious underlying complications.

Description

Pressure sores can range in stages from moderate to severe. In appearance they can look as harmless as any blister or discoloration on the skin, as in mild bruises or scrapes. The National Pressure Ulcer Advisory Panel (NPUAP), with a concern for preventing and treating pressure sores, has designated four categories, or stages in determining their severity. According to the NPUAP, deep tissue injury can become first known by discolored skin that has a maroon or purplish tone, or the appearance of a blood-filled blister. Sometimes skin spots will simply feel painful to the touch, firmer or a different temperature from the surrounding areas. In people with darker skin tones, detecting deep tissue injury if often more difficult than in lighter-skinned people. Due to evolution, a thin blister might actually develop over a dark wound bed, according to the NPUAP. Further, also due to what has developed through evolution, a thin scab might cover the wound underneath—while that wound is growing deeper and more problematic.

Stage I, of pressure sores are indicated first by a red spot that itches or hurts, and might feel warm or spongy when it is touched. Darker-skinned individuals such as those of African, Spanish, or Mediterranean descent might have skin that is blue or purple in tone, or ashen, and easily flakes. If properly observed, and if the pressure source is relieved, this is considered a superficial wound that can disappear in a short period of time.

Stage II, is so designated because skin has probably already broken, and shows a wound bed that is pinkish red in color. This can be at the epidermis or outermost layer, or the dermis, the deeper layer of skin. Sometimes it is actually a blister-like opening and can be filled with liquid. Most likely, it will be shiny if the skin is not already broken. Skin tears that might result from bandage tape irritation, perinealdermatitis , chafing, or other similar breakdown of skin. At this stage pressure sores will also heal in a short period of time if treated with proper care.

Stage III, ulcers indicate that the condition has reached a critical stage, and that the damage runs to a deeper layer of the skin, even though there is yet no bone or tendon visible. NPUAP refers to this as full thickness tissue loss, in which the fat under the skin can be visible, but without the bone, tendon, or muscle exposed. At this stage the wound is deep, with a crater-like appearance.

Stage IV, is the most serious of the stages and indicates severe loss of skin, affecting muscle, bone, and even tendons and joints. These are the most dangerous because of the depth of the open wound—making an individual subject to possible life-threatening infections. At this stage, the wounds, especially in diabetics or people with other immune disorders, are difficult to heal, and will probably require prolonged treatment.

The NPUAP has also determined that some pressure sores are Unstageable. These are sores that might be covered with dead tissue (slough) that can be yellow, tan, gray, green, or brown; or, the pressure sore might be covered over with a scab-covering, also referred to as eschar, the color of tan, brown, or black. In order to determine the stage of wound in this circumstance, the covering or scab would have to be removed so the base of the wound can be examined.

Pressure sores develop wherever a person is most likely to have sustained pressure. For someone in a wheelchair, sores are likely to develop on the tailbone, buttocks, should blades, spine, or on the backs of arms and legs that might rest on or against the chair. For those who are in bed for long periods of time due to paralysis, coma , or recovery from an illness or surgery, pressure sores might develop on the back or sides of the head, along the rims of the ears, on the shoulders or shoulder blades, the hipbones, tailbone, or lower back, as well as on the heels of the feet, the backs or sides of the knees, ankles or toes.

QUESTIONS TO ASK YOUR DOCTOR

• How does diabetes affect my condition?
• Will I have permanent scarring from pressure sores?

Demographics

Anyone subject to long periods of inactivity, and confined to a bed or a wheelchair is especially vulnerable to pressure sores. The highest incidence is likely to occur in those individuals suffering from spinal cord injuries, Due to the permanent nerve damage often suffered due to the injuries, skin and other tissues experience ongoing compression. Thinning or atrophied skin, decreased circulation—movement enables the flow of oxygen that helps to keep skin from developing sores and other infections—and no nerve signal to indicate discomfort due to a prolonged position, all combine to make the person with spinal cord injuries at the greatest risk for pressure sores. Others at risk for this condition are those over 70. With thinning skin, nutrition deficiencies, underweight, lower activity rates, the possibility of developing pressure sores, and the problem of healing them causes the increased risk to the older adult. People with diabetes, and vascular diseases are also at a greater risk than the general population—should the conditions comprising the dangers of pressure sores arise. As with the other risk factors, the lack of circulation and oxygen flow necessary to heal wounds is compromised.

Other external factors that can cause an increased risk of pressure sores include nursing home residence due to the fact that people who have been hospitalized or are in a nursing home are probably frail, and where the volume of patients might create negligence in care; a lack of pain perception; natural thinnes or weight loss from illness or prolonged healing of such conditions as hip surgery; malnutrition ; urinary or fecal incontinence , with skin staying moist and thus more vulnerable to breakdown; muscle spasms or

contracted joints that can make a person more vulnerable to repeated trauma from friction or shear forces.

KEY TERMS

subcutaneous —Under the skin, or a layer of skin

epidermis —The outermost layer of skin

perineal —Pertaining to the area known as the perineum, between the anus and the vulva in women, and between the anus and scrotum in the men.

Causes and symptoms

Sustained pressure on vulnerable areas of the skin is the first and foremost cause of pressure sores. When anyone is in a position that is maintained without shifting the pressure on a particular spot or spots, or physical movement or activity is minimal, pressure sores are likely to occur, especially in those who are paralyzed, or have long illnesses that require them to be immobile. Whether a person is underweight, or overweight, pressure sores can develop—with those who are not cushioned by much fat or muscle over areas just as a spine, tailbone, shoulder blade, hip, heels, or elbows being especially vulnerable. With the skin and underlying tissues caught between the bone and the surface of something like a wheelchair or bed, blood does not flow properly. Consequently, oxygen and other nutrients necessary for proper healing and maintenance are not available to the skin. When a person is so confined, even clothing, bed linens, chair or bed tilt, and perspiration can aggravate the skin—it softens under these circumstances and then is susceptible to injury. Even turning too frequently can be harmful if it causes friction and irritation to the skin, causing breakdown. Shear that arises when the skin moves in one direction but the underlying bone moves in another—as in sliding down in a bed or chair (often occurring in those who are lying in bed or sitting in a wheelchair for long periods of time) or raising the head of the bed more than 30 degrees—stretches and tears cell walls and the tiny blood vessels, and thus causing skin breakdown.

Smokers have an increased risk of pressure sores over non-smokers. Due to nicotine impairing circulation, and reducing the amount of oxygen flowing through the blood, skin breakdown is more likely to occur, and healing is likely to be more difficult. In those with impaired mental facilities pressure sores are a danger most often because they are less able to care for nutrition, take proper medications, or take other precautions that can prevent this condition.

Diagnosis

Physicians, physician assistants, nurses, or other medical professionals will diagnose pressure sores even in their initial stages by simple visibility. Experienced professionals will be able to see immediately that something is wrong. Diagnosis will extend to various blood tests, urine analysis and culture, stool culture, and in severe cases that are not healing despite aggressive treatment, a biopsy of the tissue will be taken to determine a complete bacterial analysis. In this case, a cancer biopsy might also be taken because of the increased risk people have with wounds that do not heal after a long period of time.

Treatment

Because open wounds can take a long time to close, treatment can be a slow and arduous process. Due to damaged skin and tissues, even when wounds are healed, evidence remains in scarring or fragile skin. Because the problem of healing is complicated, and often the individual is in fragile health already, care is necessary for medical, emotional, and even social aspects that arise with the condition. Primary care physicians and nurses are the important first step in diagnosis, and will assist in the process that might involve social workers, physical therapists, urologists, gastroenterologists, and for diabetics, endocrinologists if other than the primary physicians. When a wound requires surgery for repair, a neurosurgeon, orthopedic surgeon, and plastic surgeon might also be involved. In a study reported by the Journal of the American Geriatrics Society in August 2007, 52 nursing homes around the United States participated in determining how best to treat pressure sores in clients. Due to collaborative efforts by every department from the laundry to the hair salon, from the kitchen staff to the health care professionals, severe pressure sores that had been acquired within the institutions themselves were reduced by 69 percent.

When the sores are classified as stage I or II sores, treatment will involve nonsurgical measures—the first and most important being to remove the person from the situation that can aggravate the sores or cause new ones. These can include various options. One of them is changing positions often—every 15 minutes for those in wheelchairs, and every two hours for those who are confined to bed, and using sheepskin or other padding

to protect the wound from friction caused by movement. Another would be using other pads and measures of support such as foam, air, or water-filled mattresses or cushions to use while sitting or lying, using care to avoid using pillows and rubber rings that can cause compression. Physicians and health-care professionals recommend low-air-loss beds or air-fluidized beds. Inflatable pillows are used with low-air-loss beds to provide support. Air-fluidized beds work by suspending an individual on an air-permeable mattress filled with millions of silicon-coated beads.

Whether a pressure sore involves an open wound, or is only in stage I, regular cleaning is critical in order to prevent infection. Stage I sores can be cleansed with a mild soap and warm water. Open sores must be cleaned with a saline (salt water) solution every time the dressing is changed. A simple saline solution can be prepared at home by boiling one teaspoon of salt in one quart of water for five minutes, or can be purchased at a drug store. The container in which it is stored must be sterile if it is made at home, and should not be used until it is cooled. Topical antiseptics such as hydrogen peroxide and iodine should be avoided. These can cause irritation and damage to the sensitive tissue and in fact will likely delay healing. Because moisture on the skin surrounding a wound will continue to aggravate the condition, incontinence is also a crucial issue to address. If bladder or bowel problems exist, people should consult a physician to help them address it—whether it involves a lifestyle change, behavioral programs, bed pads or adult care products, or medications.

Any dressings used to treat pressure sores must provide protection of the wound in order to speed the healing process. Usually stage I wounds will not require a dressing or bandage. Stage II sores are often approached by using hydrocolloids which are transparent semipermeable dressings designed to hold in the moisture and encourage skin cell growth.

Removal of damaged tissue, also known as debridement, can be accomplished through surgery. More commonly it is done by using a nonsurgical high-pressure device that causes the body's enzymes to break down dead tissue. Another form of debridement is the application of topical debriding enzymes.

Hydrotherapy (using whirlpool baths) are helpful with those who can tolerate them, as they clean the wounds and assist in removing contaminated or dead tissue. Relief from muscle spasms also helps to prevent and to treat pressure sores. In those instances, a physician will prescribe skeletal muscle relaxants that will serve as nerve blocking agents in the spine or in the muscle cells.

When surgery is required to heal a pressure sore, the first step is debridement—though more extensive than the nonsurgical treatment form. Not only is the dead tissue removed, but the fluid-filled sac and creates the gliding surface between the bone and the muscle, is also eliminated, including any bone that is diseased. Known as flap reconstruction, this type of surgery is extremely complicated. Recovery takes a long time and is difficult. Those who are considered the best candidates for it will have a family or social support system, excellent nutritional health, optimum resources such as a pressure-release bed, and the ability to participate actively and optimistically in their own recovery.

As of 2008, other treatments were still being investigated for their success. These include the use of hyperbaric oxygen chambers, electrotherapy, and the topical use of human growth factors—these proteins that stimulate growth have been approved for diabetic ulcers but not yet for pressure sores.

Health care professionals caution that massage should not be used in treating pressure sores. Subcutaneous tissue is prone to damage in massage.

Nutrition/Dietetic concerns

A healthy diet that promotes healing would include Vitamin C and zinc , proven to promote the healing of wounds. Physicians will often prescribe Vitamin C and zinc supplements. These, in addition to a nutrition plan that includes sufficient calories, adequate protein, and a full range of fruits and vegetables will provide crucial assistance in the process as well.

Therapy

Physical therapy, including hydrotherapy, might be necessary to assist in body movement either for those with spinal cord injuries or paralysis, or after someone has been immobile for a long period of time. This might also assist in healing open wounds by maximizing the amount of oxygen circulating throughout a person's system.

Prognosis

The most difficult pressure sores to treat are those in spinal cord patients, and thus the prognosis in such cases is difficult at best but not impossible. Studies are being conducted continually to find ways in which to provide for optimal skin care that can heal and prevent pressure sores. For anyone who is confined to bed or wheelchair, is diabetic, or suffers chronic health care

issues, success in treatment is possible even if challenging—especially if caught in the earlier stages.

Prevention

In order to prevent pressure sores in high-individuals a number o measures help. Those include the following: frequent position changes—taking care to move otherwise immobile patients at least every two hours, or moving every 15 to 20 minutes if confined to a chair or wheelchair; when lying on the hipbone on one side, the angle should be 30 degrees, not flat; providing proper leg support by placing a pillow or foam pad under the legs from the middle of the calf to the ankle, avoiding support pads directly behind the knee—a practice that can cause the flow of blood to be restricted; not placing the head at an angle more than 30 degrees; and using a pressure-reducing mattress or bed. In addition to these, daily skin inspection is essential in order to notice the first sign of a problematic skin issue that can lead to a pressure sore, or one that has already developed. Once any sign of a sore appears, seeking medical advice can be crucial. Maintaining a good weight through proper nutrition and adequate calorie intake is also essential in maintaining optimum skin health that will not provide an environment for its breakdown that can result in pressure sores.

Caregiver concerns

When caring for someone who is at a high risk for pressure sores, or might already have developed them, a multi-dimensional approach is essential. Whether or not the person is permanently immobile due to paralysis, or recovering from or suffering a long-term illness, the caregiver must serve as skin inspector, body positioning aide, and nutritional guide even if the person is participating in self-care. Infections can be life-threatening and must be avoided, or treated for optimal health.

Eat to heal

• Eat smaller meals more often in order to maintain a healthy weight
• Eat larger meals at the time when hunger is at its peak time
• Limit fluids that prevent eating higher calorie foods
• If swallowing is an issue, pureed food or liquid meals can maximize calorie intake when necessary
• Choose high protein foods that might be easier to digest than meat—cottage cheese, peanut butter, yogurt, and custards

Resources

PERIODICALS

“Fighting Bedsores With a Team Approach.” New York Times. (February 19, 2008) “Lateral Decubitus Position Generates Discomfort and Worsens Lung Function in Chronic Health Failure.” Chest Journal. (2005); 128:1511-1516).

“Wall Street Journal Examines Hospital Efforts to Reduce Pressure Sores.” Medical News Today. (September 7, 2007).

OTHER

“Bedsores (Pressure Sores).” http://www.mayoclinic.com.

“Pressure sores.” http://www.decubitus.org.

“Pressure ulcer.” http://www.nlm.nih.gov/medlineplus.

“Pressure Ulcer, Definition and Stages.” http://www.npuap.org.

“Prevention of Pressure Sores through Skin Care.” http://www.spinalcord.uab.edu/show.asp?durki=21486.

ORGANIZATIONS

National Decubitus Foundation, 4255 South Buckley Road, #228, Aurora, CO, 80013, 303-594-9417, http://www.decubitus.org.

National Pressure Ulcer Advisory Panel, 1255 Twenty-Third Street NW, Suite 200, Washington, D.C., 202-521-6789, 202-833-3636, [email protected], http://www.npuap.org.

Jane Elizabeth Spehar