Pressure ulcers, commonly called pressure sores or bedsores, are localized areas of cellular necrosis that occur most commonly 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 commonly go undetected until they penetrate the skin; by then, they have usually caused subcutaneous damage.
Five body locations together account for 95% of all pressure ulcer sites: sacral area, greater trochanter, ischial tuberosity, heel, and lateral malleolus. Patients who have contractures are at an increased risk for developing pressure ulcers because the abnormal position adds pressure on the tissue and the alignment of the bones.
Age also has a role in the incidence of pressure ulcers. Muscle and subcutaneous tissue is lost with aging, and skin elasticity decreases. Both factors increase the risk of developing pressure ulcers.
A stage 1 pressure ulcer is an observable pressure-related alteration of intact skin. The ulcer appears as a defined area of persistent redness in lightly pigmented skin; in darker skin, the ulcer may appear with persistent red, blue, or purple hues.
A stage II pressure ulcer is characterized by partial-thickness skin loss involving the epidermis or dermis. The ulcer is superficial and appears as an abrasion, blister, or shallow crater. These wounds heal within a few weeks.
A stage III pressure ulcer is characterized by full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to, but not through, the underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue.
Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or support structures (for example, tendon or joint capsule) characterizes a stage IVpressure ulcer. Tunneling and sinus tracts may also be associated with these ulcers.
Ulcers of the subcutaneous tissue and muscle may require several months to heal. If the damage has affected the bone in addition to the skin layers, osteomyelitis may occur, which will prolong healing time.
· Immobility and decreased level of activity
· Friction and shear, causing damage to the epidermal and upper dermal skin layers
· Constant moisture on the skin, causing tissue maceration
· Impaired hygiene, as with fecal incontinence, leading to skin breakdown
· Malnutrition, hypoalbuminemia
· Medical conditions such as diabetes; orthopedic injuries
· Psychological factors such as depression; chronic emotional stresses
A pressure ulcer is caused by an injury to the skin and its underlying tissues. The pressure exerted on the area restricts blood flow to the site and causes ischemia and hypoxemia. As the capillaries collapse, thrombosis occurs and leads to tissue edema and necrosis. Ischemia also contributes to an accumulation of toxins. The toxins further break down the tissue and also contribute to tissue necrosis. Secondary bacterial infections can cause rapid ulcer enlargement.
Signs and symptoms
· First clinical sign: blanching erythema, varying from pink to bright red depending on the patient's skin color; in dark-skinned people, purple discoloration or a darkening of normal skin color (when the health care provider presses a finger on the reddened area, the pressed-on area whitens and color returns within 1 to 3 seconds if capillary refill is good)
· Pain at the site and surrounding area
· Localized edema and increased body temperature due to initial inflammatory response; in more severe cases, cool skin due to severe damage or necrosis
· In more severe cases with deeper dermal involvement: nonblanching erythema, ranging from dark red to purple or cyanotic
· As ulcer progresses: skin deterioration, blisters, crusts, or scaling
· Deep ulcer originating at or extending to the bony prominence below the skin surface: usually dusky red, possibly mottled appearance, doesn't bleed easily, warm to the touch
Diagnostic test results
· Wound culture and sensitivity tests detect infectious organisms.
· Blood testing reveals elevated white blood cells, elevated erythrocyte sedimentation rate, and hypoproteinemia.
· For immobile patients, repositioning by the caregiver every 2 hours (or more often), with support of pillows; for those able to move, a pillow and encouragement to change position
· Foam, gel, or air mattress to aid in healing by reducing pressure on the ulcer site and reducing the risk of more ulcers
· Foam, gel, or air mattress on chairs and wheelchairs
· Nutritional supplements, such as vitamin C and zinc, for the malnourished patient; adequate protein intake
· Adequate fluid intake to prevent dehydration
· Meticulous skin care and hygiene practices, particularly for incontinent patients
· Transparent film, polyurethane foam, or hydrocolloid dressing
Stage III or IV
· Wound loosely filled with saline- or gel-moistened gauze; exudate managed with absorbent dressing (moist gauze or foam); covered with secondary dressing
· Surgical debridement
STAGING PRESSURE ULCERS