Pressure ulcers
Pressure ulcers: Excerpt from Professional Guide to Diseases (Eighth Edition)
Pressure ulcers, commonly called pressure sores or bedsores, are localized areas of cellular necrosis that occur most often in the skin and subcutaneous tissue over bony prominences. These ulcers may be superficial, caused by local skin irritation with subsequent surface maceration, or deep, originating in underlying tissue. Deep lesions typically go undetected until they penetrate the skin; but, by then, they’ve usually caused subcutaneous damage.
Causes and incidence
Most pressure ulcers are caused by pressure, particularly over bony prominences, that interrupts normal circulatory function, leading to ischemia of the underlying structures of skin, fat, and muscles. (See Pressure points: Common sites of pressure ulcers.) The intensity and duration of such pressure govern the severity of the ulcer; pressure exerted over an area for a moderate period (1 to 2 hours) produces tissue ischemia and increased capillary pressure, leading to edema and multiple small-vessel thromboses. An inflammatory reaction gives way to ulceration and necrosis of ischemic cells. In turn, necrotic tissue predisposes to bacterial invasion and subsequent infection.
The patient’s position determines the pressure exerted on the tissues. For example, if the head of the bed is elevated, or the patient assumes a slumped position, gravity pulls his weight downward and forward. This shearing force causes deep ulcers due to ischemic changes in the muscles and subcutaneous tissues, and occurs most often over the sacrum and ischial tuberosities.
Predisposing conditions for pressure ulcers include altered mobility, inadequate nutrition (leading to weight loss, subsequent reduction of subcutaneous tissue and muscle bulk and, possibly, a poorly functioning immune system), and a breakdown in skin or subcutaneous tissue (as a result of edema, incontinence, fever, pathologic conditions, or obesity).
Pressure ulcers occur in 10% to 17% of all hospitalized patients and 20% to 40% of all nursing home patients. Patients living at home aren’t free from risk, either: 20% of all pressure ulcers occur in the home. In the United States, there are approximately 2 million new cases of pressure ulcers diagnosed every year.
Signs and symptoms
Pressure ulcers commonly develop over bony prominences. Early features of superficial lesions are shiny, erythematous changes over the compressed area, caused by localized vasodilation when pressure is relieved. Superficial erythema progresses to small blisters or erosions and, ultimately, to necrosis and ulceration.
An inflamed area on the skin’s surface may be the first sign of underlying damage when pressure is exerted between deep tissue and bone. Bacteria in a compressed site cause inflammation and, eventually, infection, which leads to further necrosis. A foul-smelling, purulent discharge may seep from a lesion that penetrates the skin from beneath. Infected, necrotic tissue prevents healthy granulation of scar tissue; a black eschar may develop around and over the lesion.
Diagnosis
Pressure ulcers are obvious on physical examination. Wound culture and sensitivity testing of the exudate in the ulcer identify infecting organisms and antibiotics that may be needed. If severe hypoproteinemia is suspected, total serum protein values and serum albumin studies may be appropriate.
Treatment
Successful treatment must relieve pressure on the affected area, keep the area clean and dry, and promote healing. (See Special aids for preventing and treating pressure ulcers.)
Special considerations
❑ During each shift, check the skin of bedridden patients for possible changes in color, turgor, temperature, and sensation. Examine an existing ulcer for any change in size or degree of damage. When using pressure relief aids or topical agents, explain their function to the patient.
❑ Prevent pressure ulcers by repositioning the bedridden patient at least every 2 hours around the clock. To minimize the effects of a shearing force, use a footboard and raise the head of the bed to an angle not exceeding 60 degrees. Also, use a draw or pull sheet to turn the patient or to pull him up. Keep the patient’s knees slightly flexed for short periods. Perform passive range-of-motion exercises, or encourage the patient to do active exercises if possible.
❑ To prevent pressure ulcers in immobilized patients, use pressure relief aids on their beds.
❑ Provide meticulous skin care. Keep the skin clean and dry without the use of harsh soaps. Gently massaging the skin around the affected area — not on it — promotes healing. Thoroughly rub moisturizing lotions into the skin to prevent maceration of the skin surface. Change bed linens frequently for patients who are diaphoretic or incontinent. Use a fecal incontinence bag for incontinent patients.
❑ Clean open lesions with a 3% solution of hydrogen peroxide or normal saline solution. Dressings, if needed, should be porous and lightly taped to healthy skin. Debridement of necrotic tissue may be necessary to allow healing. One method is to apply open wet dressings and allow them to dry on the ulcer. Removal of the dressings mechanically débrides exudate and necrotic tissue. Other methods include surgical debridement with a fine scalpel blade and chemical debridement using proteolytic enzyme agents.
❑ Encourage adequate intake of food and fluids to maintain body weight and promote healing. Consult with the dietary department to provide a diet that promotes granulation of new tissue. Encourage the debilitated patient to eat frequent, small meals that include protein- and calorie-rich supplements. Assist weakened patients with their meals.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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