Pressure ulcers, also commonly known as bedsores, decubitus ulcers, and pressure sores, are among the most serious skin injuries. These tender or inflamed patches develop when skin covering a weight-bearing part of the body is squeezed between bone and another body part or some other hard object. The ulceration results from the loss of blood flow and oxygen (ischemic hypoxia) to the tissues owing to prolonged pressure on a body part.
Pressure ulcers are most likely to occur in people who have decreased mobility, including the frail, elderly, or seriously ill. People who have atherosclerosis (artery disease), diabetes, heart disease, incontinence, malnutrition, obesity, paralysis, and spinal cord injuries are all at high risk for developing pressure ulcers. This often-painful condition usually begins with shiny red skin that quickly blisters and deteriorates into open sores that can harbor life-threatening infections. These ulcerations are most likely to develop on the:
- back of the head
- shoulder blades
Pressure ulcers usually develop over bony prominences and are graded, or staged, to classify the amount of tissue damage that is observed. These stages are:
- Stage I. The skin is reddened, and the damage may be superficial. The first sign of skin ulceration occurs when pressure squeezes the tiny blood vessels that supply the skin with nutrients and oxygen. The area does not return to its normal appearance after the source of pressure is removed.
- Stage II. There is partial-thickness skin loss involving the epidermis (outer layer), the dermis (inner layer), or both. The skin is blistered, peeling, or has a shallow crater, though the damage is still minor.
- Stage III. There is full-thickness skin loss involving damage to, or necrosis (death) of, the subcutaneous (under the skin) tissue. It may extend down to, but not through, the underlying fascia (connective tissue). This type of ulcer usually appears as a deeper crater. Drainage may be seen.
- Stage IV. Full-thickness skin loss is present, with extensive tissue destruction and damage to muscle, bone, or the supporting structures such as tendons. This stage of ulceration is associated with high morbidity.
Causes and symptoms
The primary risk factors leading to the formation of a pressure ulcer include all of the following:
- Pressure. Very intense pressure, even if it occurs for a short time, may cause a pressure ulcer. Less intense pressure that lasts over a long period of time may also cause ulceration.
- Friction. This phenomenon occurs when two forces move against each other. When a patient's skin is dragged or pulled over bed sheets, friction occurs, with possible tissue injury resulting. The friction injury often happens when a patient is pulled, instead of lifted, up in bed.
- Shear. Deeper than a friction injury, shear happens when the skin located over a bony prominence slides over a hard surface. The skin and surrounding structures remain in one position because pressure keeps the skin stuck to a surface such as bed sheets. The shearing literally tears at the skin, the subcutaneous layer, and the muscle as well. Deep tissue injury and vascular damage may occur.
- Tissue maceration. Prolonged moisture on the skin can decrease the skin's resiliency and alter its pH (the measure of acidity and alkalinity).
Pressure ulcers usually develop in six stages:
- erythema, swelling of tissue, and possible peeling of the outer layer of skin
- dead skin, draining wound, and an exposed layer of subcutaneous tissue
- tissue necrosis through the skin and subcutaneous layers, into the muscle
- inner fat and muscle necrosis
- destruction of bone, local infections, and potential for sepsis
Physical examination, medical and nursing history, and patient and caregiver observation are the basis of diagnosis. Special attention must be paid to any physical or mental impairment such as incontinence or confusion that could complicate a patient's recovery. Staging is done based on the wound's characteristics and depth of soft tissue damage. Correct staging can only be done after all necrotic (dead) tissue has been removed, allowing for complete inspection of the wound bed (area). According to the National Pressure Ulcer Advisory Panel, once a particular stage (I, II, III, or IV) has been assigned to a pressure ulcer, it will always remain at that stage. Although pressure ulcers will heal to progressively more shallow depths, they do not replace the lost muscle, fat, or dermis. Instead, the ulcer is filled in with scar tissue. Therefore, when a Stage IV ulcer has healed, it should be classified as a healed Stage IV ulcer, not a Stage 0 ulcer.
The desired outcomes of pressure ulcer treatment are to protect the remaining healthy cells, heal the ulcer completely, and prevent the formation of other pressure ulcers. If addressed promptly, surface pressure ulcers can be prevented from developing into more serious wounds.
Pressure ulcer management contains four basic components:
- Debridement. This is a procedure that involves the removal of dead tissue or other debris from the wound. Debridement can be done by a sharp method, where the tissue is actually cut out with a scalpel or other sharp instrument, and is usually performed by a physician, physician's assistant, or an advanced practice nurse. Another method is mechanical debridement, which utilizes wet-to-dry dressings, wound irrigation, and dextranomers (beads placed into the wound bed to absorb drainage). Enzymatic debridement utilizes certain topical debriding agents to help remove the dead tissue. Autolytic debridement uses synthetic dressings that help the involved tissue self-digest from enzymes that are contained in wound fluids. This last method should not be used for infected pressure ulcers.
- Cleansing. Normal saline is the recommended solution for cleansing wounds because it does not harm the wound bed, and it adequately cleanses the majority of wounds. Solutions such as hydrogen peroxide, povidone iodine, iodophor, and acetic acid are cytotoxic (toxic to cells), and should not be used. There are several commercially prepared wound cleansers containing surfactants (surface-active substances) and other ingredients, but these may also have some toxic effects on the cells. In order to minimize wound damage during cleansing, appropriate irrigation methods should be used. Too little pressure, such as that produced with a bulb syringe, yields poor results; while too much pressure will cause damage to healthy tissue. Irrigating the ulcer using a 35-ml syringe with a 19-gauge angiocatheter will usually provide enough pressure to get rid of eschar (scabs), bacteria, and other debris. In addition, the use of daily whirlpool treatments may help facilitate the removal of necrotic tissue.
- Infection management. Because of the various factors that may affect a patient's resistance to infection, the patient should be closely monitored for any signs of infection in the wound so that antibiotics can be initiated promptly. These signs include a sudden deterioration of the ulcer, changes in the color or texture of the granulation (new capillaries formed on the surface of a wound in healing) tissue, or alterations in the amount or appearance of the wound drainage. In addition, any increase in redness, edema, or tenderness of the ulcerated area should be reported to the physician.
- Dressings. When selecting a dressing for a pressure ulcer, the most important factor is the ability of the dressing to keep the wound bed moist and the surrounding healthy, intact skin dry. There are numerous types of dressings available; and selection should be determined based on the preference of the physician and nurse, the time available to perform wound care, and the specific conditions of each wound.
Other adjunctive treatments that promote healing include electrical stimulation, ultrasound, hyperbaric (high pressure) oxygen, and laser irradiation. If there is extensive tissue necrosis, or if there are signs of infection, the physician may order topical and/or systemic antibiotic treatment. Very deep ulcers that do not respond to treatment may require skin grafts or plastic surgery.
Many patients are interested in complementary or alternative treatments, and several have been suggested in the treatment of pressure ulcers. Zinc and vitamins A, C, E, and B complex help skin repair injuries and stay healthy, but large doses of vitamins or minerals should not be used without consulting a physician. Various herbal remedies, including a tea tree oil rinse and an herbal tea made from the calendula plant, may act as antiseptic agents. Again, the physician or health care professional should be consulted when considering any of these treatments.
With prompt, appropriate treatment, pressure ulcers should begin to heal in two to four weeks. If the ulcer exhibits no signs of progress in three weeks, the treatment plan should be reevaluated. The National Pressure Ulcer Advisory Panel recommends that if a non-healing wound is clean, then the ulcer should be treated with topical antibiotics. If the bedsore still does not respond within two weeks, then other factors need to be explored.
Health care team roles
Several members of the health care team are important when treating the patient with a pressure ulcer. The physician orders treatment and performs any necessary surgical interventions. The nurse plays a primary role in assessing the wound and administering treatment, consulting with the physician on wound care decisions, and providing patient education. Physical therapists may also participate in pressure ulcer care by providing whirlpool treatments.
It is usually possible to prevent pressure ulcers from forming and/or worsening. A variety of measures can be taken to accomplish this goal. At-risk individuals should be identified. These individuals include those with a history of previous pressure ulcers, since healed full-thickness pressure ulcers have only 80% of the strength of non-injured skin. A systematic skin assessment should be performed daily on all patients at risk for ulcer formation. Because a health care professional may not be available to assess homebound patients, the family or other caregivers should be educated on the symptoms of early skin breakdown and on when to notify their health care professional.
Cytotoxic— The characteristic of being destructive to cells.
Ischemia— The temporary deficiency of blood flow to a tissue or organ.
Necrotic— Relating to the death of a portion of tissue.
Other methods of pressure ulcer prevention are:
- Always cleanse the skin of incontinent patients at the time of soiling.
- Moisturize dry skin to keep it well hydrated.
- Turn and reposition the patient at least every two hours. Keep a turning schedule posted at the bedside.
- Utilize proper patient positioning, lifting, and transferring methods to avoid friction and shear. Use a lift sheet when moving the patient.
- Use pillows or cushions to pad bony prominences and support limbs.
- Consider using an alternating pressure mattress or other support surface designed to reduce pressure on the skin.
- Do not massage bony prominences, as this could cause deep tissue damage.
- Encourage adequate consumption of protein, calories and fluids.
- Maintain or improve the patient's activity level. Perform range of motion exercises, if possible.
- Instruct the patient, family, and any other caregivers regarding appropriate preventive care.
Ignatavicius, Donna D., et al. Medical-Surgical Nursing Across the Health Care Continuum. Philadelphia: W.B. Saunders Company, 1999.
Calianno, Carol. "Assessing and Preventing Pressure Ulcers." Advances in Skin and Wound Care (October 2000): 244.
Cervo, Frank A., et al. "Pressure Ulcers—Analysis of Guidelines for Treatment and Management." Geriatrics (March 2000): 55.