Pressure Ulcers

Pressure ulcers are also referred to as pressure sores, bedsores, and decubitus ulcers. A pressure ulcer can range from a very mild pink coloration to the skin which disappears in a few hours after the pressure is relieved, to a very deep wound extending to and sometimes through a bone into internal organs.

All pressure ulcers have a course of injury similar to a burn wound. This can be a mild redness of the skin and/or blistering such as a first degree burn to a deep open wound with a lot of blackened tissue in it such as a third or fourth degree burn. This black tissue is called eschar.

Causes

Pressure ulcers tend to develop on areas of the body that have little body fat to cover them. This includes the hips, heels, shoulder blades and the small of the back. They occur when a person is immobile for a long period of time, for example, when a person has been ill in bed or in hospital. Sitting in a chair or wheelchair for long periods of time, without pressure being relieved can also cause pressure ulcer development.

Pressure ulcers occur when pressure is applied to the same area of the body for an extended length of time. This prevents blood traveling to the area and restricts the flow of oxygen, causing body tissue to die.

Symptoms

Pressure ulcers appear over bony parts of the body where there is irritation or pressure. The symptoms develop in stages:

• Stage I: A reddened or darkened area of skin appears and does not go away within 30 minutes after you change your position to put less pressure on the area.
• Stage II: The skin cracks, blisters, peels, or breaks.
• Stage III: The skin opens up and may ooze or drain. The ulcer is completely through the skin and may start to involve underlying tissues. Some yellow tissue may be seen.
• Stage IV: A deep ulcer develops. Muscle is visible. Bone may also become visible.

Diagnostic tests

Wound culture and sensitivity testing of the ulcer exudate are used to identify infecting organisms. Serum protein and serum albumin studies may be ordered to determine severe hypoproteinemia.

Treatment

Prevention is most important in pressure ulcers, by such means as movement and exercise to improve circulation and adequate nutrition to maintain skin health. When pressure ulcers do develop, successful management involves relieving pressure on the affected area, keeping the area clean and dry, and promoting healing. To relieve pressure, devices such as pads, mattresses, and special beds may be used. Turning and repositioning are still necessary. In addition, a diet high in protein, iron, and vitamin C helps to promote healing.

Other treatments depend on the ulcer stage. Stage 1 treatment aims to increase tissue pliability, stimulate local circulation, promote healing, and prevent skin breakdown. Specific measures include the use of lubricants (such as Lubriderm), clear plastic dressings (Op-Site), gelatin-type wafers (DuoDerm), vasodilator sprays (Proderm), and whirlpool baths.

For stage 2 ulcers, additional treatments include cleaning the ulcer with normal saline solution. This removes ulcer debris and helps prevent further skin damage and infection.

Therapy for stage 3 or 4 ulcers aims to treat existing infection, prevent further infection, and remove necrotic tissue. Specific measures include cleaning the ulcer with povidone-iodine solution and applying granular and absorbent dressings. These dressings promote wound drainage and absorb any exudate. In addition, enzymatic ointments (such as Elase or Travase) break down dead tissue, whereas healing ointments clean deep or infected ulcers and stimulate new cell growth.

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 debrides exudate and necrotic tissue. On occasion, the ulcer may require debridement using surgical, mechanical, or chemical techniques. In severe cases, skin grafting may be necessary.

Prevention

If bedridden or immobile with diabetes, circulation problems, incontinence, or mental disabilities, you should be checked for pressure sores every day. Look for reddened areas that, when pressed, do not turn white. Also look for blisters, sores, or craters. In addition, take the following steps:

• Change position at least every two hours to relieve pressure.
• Use items that can help reduce pressure -- pillows, sheepskin, foam padding, and powders from medical supply stores.
• Eat healthy, well-balanced meals.
• Exercise daily, including range-of-motion exercises for immobile patients.
• Keep skin clean and dry. Incontinent people need to take extra steps to limit moisture.

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