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Three major factors in the development of pressure ulcers are (1) prolonged pressure on a part due to the weight of the body or a limb; (2) a shearing force that exerts downward and forward pressure on tissues beneath the skin (this can occur when the patient slides downward while sitting in a bed or chair, or when bedclothes are forcibly pulled from under the patient); and (3) nutritional status: good nutrition is essential for preventing pressure ulcers and healing already existing ones; a dietary deficiency should be suspected with a loss of 5 per cent or more of body weight or a serum albumin level below 3.5 mg/dl.
A pressure ulcer usually occurs over a bony prominence at the sacrum, hip (trochanter), heel, shoulder, or elbow. The lesion begins as a reddened area, which can quickly involve deeper structures and become an ulcer.
In Stage 1 the area of skin is deep pink, red, or mottled. Digital pressure on the area will cause temporary blanching for up to 15 minutes after pressure is released. The skin will feel very warm and firm or tightly stretched across the area. At this stage no destruction of tissue has occurred and the condition is reversible. It is essential that the area be relieved of prolonged pressure, and that shearing forces be avoided. The reddened area may need protection by covering it with either a transparent film or a skin barrier.
Stage 2 is characterized by blistering, cracking, or abrasion of the skin. The surrounding skin is reddened and probably will feel hot or warmer than normal. Since there is now an opening in the skin for the entrance of bacteria, treatment must include cleaning the wound and providing some type of dressing or cover in addition to relieving pressure on the area.
Stage 3 is characterized by a craterlike sore with involvement of the underlying structures. Bacterial infection is almost always present at this stage and accounts for continued erosion of the ulcer and the production of drainage. Irrigation of the wound usually is done each time the dressing is changed. Wound débridement may be necessary to promote healing.
At Stage 4 there is deep ulceration and necrosis involving underlying muscle and possibly bone tissue. At this point the ulcer usually is extensively infected. It can be dry, black in color, and covered with a tough accumulation of necrotic tissue, or it can be wet and oozing dead cells and purulent exudate. Deep and extensive ulceration and tissue loss may require surgical repair with myocutaneous flaps to close the defect.
Topical applications vary widely. The diligence with which the prescribed regimen is carried out greatly influences its effectiveness. Guidelines summarizing current recommended practice for the treatment of pressure ulcers (publication number 95-0653) are available from the Agency for Health Care Policy and Research, P.O. Box 8547, Silver Spring, MD 20907-8547 (telephone 800-358-9295).
pressure ulcerBedsore A decubitus ulcer on dependent sites, usually lumbosacral, but also on heels, knees, or vertebrae, which is most common in the bed-ridden elderly, seen in up to1⁄4 of nursing home residents, and associated with an ↑ mortality Risk factors Nonblanchable erythema, lymphopenia, immobility, dry skin, ↓ body weight, activity limited to bed or chair Management A 'cocktail' of recombinant PDGF, proteases, cell-adhesion molecules may induce healing of recalcitrant PUs.
de·cu·bi·tus ul·cer(dē-kyū'bi-tŭs ŭl'sĕr)
Synonym(s): bedsore, bed sore, pressure sore, pressure ulcer.
The most common sites of skin breakdown are over bony prominences (the sacrum and the trochanters, the heels, the lateral malleoli and also the shoulder blades, ischial tuberosities, occiput, ear lobes, elbows, and iliac crests). The combination of pressure, shearing forces, friction, and moisture leads to tissue injury and occasionally necrosis. If the ulcer is not treated vigorously, it will progress from a simple red patch of skin to erosion into the subcutaneous tissues, eventually extending to muscle or bone. Deep ulcers often become infected with bacteria and develop gangrene. See: illustration
Treatment and Prevention
The most important principle is to prevent the initial skin damage that promotes ulceration. In patients at risk, aggressive nursing practices, such as frequent turning of immobile patients and the application of skin protection to bony body parts, are frequently effective. Gel flotation pads, alternating pressure mattresses, convoluted foam mattresses and sheepskins or imitation sheepskins may be employed. Specialized air-fluid beds, waterbeds, or beds with polystyrene beads provide expensive but effective prophylaxis. If the patient develops an ulcer, topical treatments with occlusive hydrocolloid dressings, polyurethane films, absorbable gelatin sponges, collagen dressings, wound-filter dressings, water-vapor permeable dressings, and antibiotic ointments aid the healing of partial-thickness sores. Deeper lesions may need surgical débridement. Skin-damaging agents such as harsh alkaline soaps, alcohol-based products, tincture of benzoin, hexachlorophene, and petroleum gauze should be avoided. Consultation with a wound care specialist is advantageous.
The skin is thoroughly cleansed, rinsed, and dried, and emollients are gently applied by minimizing the force and friction used, esp. over bony prominences. Patients who are not able to position themselves are repositioned every 1–2 hr to prevent tissue hypoxia resulting from compression. A turning sheet or pad is used to turn patients with minimal skin friction. Care providers should avoid elevating the head of the bed higher than 30° (except for short periods) to reduce shearing forces on the skin and subcutaneous tissues overlying the sacrum. Range-of-motion exercises are provided, early ambulation is encouraged, and nutritious high-protein meals are offered. Low-pressure mattresses and special beds are kept in proper working order. Doughnut-type cushions should not be used because they decrease blood flow to tissues resting in the center of the doughnut.
Ulcers are cleansed and débrided, and other therapeutic measures are instituted according to institutional protocol or prescription. Consultation with a nutritionist may be needed to assess and optimize the patient's nutritional status, and to provide high-protein meals with added vitamin C to promote healing, protein and calorie-rich supplements, or enteral feedings. Weak or debilitated patients should be assisted to eat, with care taken to prevent swallowing difficulties.
|Mean LOS:||13 days|
|Description:||SURGICAL: Skin Graft and/or Débridement for Skin Ulcer or Cellulitis With Major CC|
|Mean LOS:||5.3 days|
|Description:||MEDICAL: Skin Ulcers With CC|
Approximately 1 million pressure ulcers occur each year in the United States, and 2% to 30% of hospitalized patients develop pressure ulcers, with elderly and critically ill patients at highest risk.
A pressure ulcer is an irregularly shaped, depressed area that results from necrosis of the epidermis and/or dermis layers of the skin. Prolonged pressure causes inadequate circulation, ischemic ulceration, and tissue breakdown. Muscle tissue seems particularly susceptible to ischemia. Pressure ulcers may occur in any area of the body but occur mostly over bony prominences that can include the occiput, thoracic and lumbar vertebrae, scapula, coccyx, sacrum, greater trochanter, ischial tuberosity, lateral knee, medial and lateral malleolus, metatarsals, and calcaneus. Some 96% of pressure ulcers develop in the lower part of the body, with the hip and buttock region accounting for almost 70% of all pressure sores.
Pressure ulcers are the direct cause of death in 7% to 8% of all patients with paraplegia, and of those patients who develop pressure ulcers in the hospital, more than half will die within a year. Pressure ulcers have been staged by the National Ulcer Advisory Panel (Table 1), but the stages serve as a description only and do not necessarily provide an order for progression.
|I||Nonblanchable erythema; involves changes in the underlying vessels of the skin; bright red color that does not resolve after 30 min of pressure relief; can be painful and tender|
|II||Partial thickness skin loss of epidermis and dermis; cracks or blisters on skin with erythema and/or indurations|
|III||Full-thickness skin loss of epidermis and dermis; extends down to subcutaneous tissue; appears as a crater or covered by black eschar, wound base usually not painful; indistinct borders; may have sinus tracts or undermining present|
|IV||Full-thickness skin loss with extensive destruction of tissue, muscle, bone, and/or supporting structures; appears as a deep crater or is covered by thick eschar; wound base not painful; may have sinus tracts and undermining present|
The most important mechanism that causes pressure ulcer formation is unrelieved pressure, leading to tissue compression and prolonged ischemia. When external pressure exceeds normal capillary pressure of 25 mm Hg, blood flow in the capillary beds is decreased. When the external pressure surpasses arteriole pressure, blood flow to the area is impaired. Ischemia occurs when the pressure exceeds 50 mm Hg and blood flow is completely blocked. Pressure from the bony prominence is transmitted from the surface of the body to the underlying bone, and all underlying tissues are compressed.
Pressure ulcers caused by shearing or friction result when one tissue layer slides over another. Shearing results in stretching and angulating of blood vessels, causing injury and thrombosis to the area. Friction occurs when two surfaces move across one another, leading to tissue drag and injury. These injuries commonly occur when the head of the bed is elevated, causing the torso to slide downward or when people are moved across bed sheets.
No clear genetic contributions to susceptibility have been defined.
Gender, ethnic/racial, and life span considerations
Pressure ulcers can occur at any age and across both genders but are more prevalent in the elderly population over age 70. About 25% of the elderly have some type of pressure ulcer, and most of these individuals are women because of their survival advantage over men. Pressure ulcers are also common in individuals who are neurologically impaired and immobile; most younger individuals suffering from pressure ulceration are males, which reflects the greater number of young men suffering traumatic spinal cord injuries. There are no known racial and ethnic considerations, but patients with dark skin may have more severe pressure ulcers and a higher rate of complication than patients with light skin due to difficulty visualizing blanching and redness in early stage ulcers.
Global health considerations
Pressure ulcers occur around the globe and have a higher incidence in older people and people who are immobilized because of chronic conditions such as stroke or spinal cord injury.
Generally, patients have a history of a condition that causes decreased circulation and sensation leading to inadequate tissue perfusion. Associated diseases and conditions include diabetes mellitus, arterial insufficiency, peripheral vascular disease, and decreased activity and mobility or spinal cord injury. Patients with casts, braces, and splints are also predisposed to developing pressure ulcers.
The most common symptom is an area of breakdown or lesion on the skin resulting from unrelieved pressure. The clinical manifestations of pressure ulcers are generally described in four stages that reflect the amount of tissue injury and the degree of underlying structural damage. Assess the wound to determine the precise location, along with size and depth. The color of the wound (whether pink, red, yellow, or black) indicates the stage of healing and the presence of epithelial tissue. A beefy red color signifies the presence of granulation tissue and denotes adequate healing. Black tissue indicates necrotic and devitalized tissue and signifies delayed healing. Observe for areas of sinus tracts and undermining, which indicate deeper involvement under intact wound margins. Determine the amount of drainage and the type, color, odor, consistency, and quantity. Assess the area around the wound for redness, edema, indurations, tenderness, and breakdown of healed tissues to identify signs and symptoms of infection.
The patient may exhibit signs of anxiety and depression because of the potential setback in an already long list of medical problems. The condition may slow the patient’s progress toward independence or necessitate a move from home to a nursing home for an elderly patient.
|Test||Normal Result||Abnormality With Condition||Explanation|
|Skin or wound culture and sensitivity||Negative for microorganisms||Positive for microorganisms||Some pressure ulcers become infected, which slows healing|
Other Tests: Supporting tests include hemoglobin and hematocrit levels (weekly), white blood cell differentials, and albumin and total protein levels.
Primary nursing diagnosis
DiagnosisImpaired skin integrity related to pressure over bony prominences or shearing forces
OutcomesTissue integrity: Skin and mucous membranes; Wound healing: Primary intention; Immobility consequences: Physiological; Knowledge: Treatment regimen; Nutritional status; Tissue perfusion: Peripheral; Treatment behavior: Illness or injury
InterventionsWound care; Skin surveillance; Positioning; Pressure management; Pressure ulcer prevention; Medication administration: Topical; Circulatory precautions; Infection control; Nutrition management
Planning and implementation
In the early stages, pressure ulcers are best handled by nursing rather than medical interventions. Surgical intervention may be necessary to excise necrotic tissue in late stages of ulcer development. Skin grafts or musculocutaneous flaps may be indicated in very deep wounds in which healing is difficult or has been unsuccessful in completely covering the area. Drains may be inserted to prevent fluid buildup in the wound. The drains facilitate the removal of blood and bacteria from the wound that can increase the risk of infection. Cleaning solutions include normal saline solution (when there is no infection present); diluted povidone-iodine for bacteria, spores, fungi, and viruses; acetic acid (0.5%) for Pseudomonas aeruginosa; and sodium hypochlorite (2.5%) for cleansing and débridement.
Mechanical débridement by an enzymatic agent (collagenase [Santyl]) may be ordered. Other types of wound care dressings include hydrocolloid, hydrogels, calcium alginates, film dressings, and topical agents and solutions. The type of dressing depends on the depth of the wound and the amount of débridement of necrotic tissue or support of granulation tissue required. In general, the following guidelines are helpful in ulcer management, although management may depend on the particular ulcer and patient:
- Stage I ulcers require no type of dressings.
- Stage II pressure ulcers are treated with moist or occlusive dressings to maintain a moist, healing environment.
- Stage III ulcers require débridement, usually with an enzymatic agent or wet-to-moist normal saline soak.
- Stage IV ulcers are treated like stage III ulcers or by surgical excision and grafting.
All wounds are assessed before treatment because all wounds are different, and similar treatments may not be successful for dissimilar wounds. Other therapies include supplementing the patient’s nutrition, hyperbaric oxygen therapy for wounds that are deep and difficult to treat, and electrotherapy to deliver low-intensity direct current to wounds in attempts to assist the healing process.
|Medication or Drug Class||Dosage||Description||Rationale|
|Hydrocolloids||No dosage; prepackaged wafers||Occlusive, adhesive wafers such as DouDerm or ConvaTac||Provides a moist, occluded, and protective environment for shallow wounds with light exudates; may remain in place for 3–5 days; retains moisture, absorbs exudates, and causes auto-débridement|
|Hydrogels||No dosage; topical gel||Glycerin-based gel such as IntraSite||Gel promotes healing by rehydrating necrotic tissue, facilitating débridement, and absorbing exudates to maintain moist environment; retains moisture and causes auto-débridement|
|Alginates||No dosage; prepackaged pads||Pads formed from brown seaweed; Kaltostat||Absorbent; used to treat deep wounds with heavy drainage|
|Adhesive films||No dosage; prepackaged pads||Plastic, self-adhering membrane; Tegaderm||Self-adhering but waterproof wafers that are permeable to oxygen and water vapor; appropriate for partial-thickness wounds; useful as secondary dressings for wounds treated with hydrocolloids or alginates; retains moisture and causes auto-débridement|
|Foams||No dosage, prepackaged||Sheets and fillers||Obliterates dead space in the ulcer; retains moisture, absorbs exudates, and causes auto-débridement|
Experimental Treatments: Cytokine growth factors such as recombinant platelet–derived growth factors and basic fibroblast growth factors and skin equivalents
The most important nursing intervention is prevention. Identify patients who are at risk by using assessment tools such as the Braden scale or the Norton scale, which determine the sensory and physiological factors that increase the incidence of pressure ulcers. The high-risk patient needs turning and proper positioning at least every 2 hours. Pressure-relieving devices, such as silicone-filled pads and foam mattresses, may be helpful. Dynamic devices include specialty beds (low air loss, air fluidized, and air cushions). Airflow pressure mattresses are also useful preventive strategies.
Keep the patient’s skin dry. Patients who are incontinent of feces and urine should be cleaned as soon as possible to prevent skin irritation. When soiling of the skin cannot be controlled, use absorbent underpads and topical agents that act as moisture barriers. Avoid the use of hot water and use a mild cleansing agent to minimize dryness and irritation in high-risk patients. Treat dry skin with moisturizers, but use care in massaging bony prominences as this may impede capillary blood flow and increase the risk of deep tissue injury. Lift high-risk patients up in bed instead of pulling them, which increases the risk of shearing and friction forces on the skin’s surfaces. To prevent the patient from sliding down in bed, do not elevate the patient’s head more than 20 degrees unless this angle is contraindicated because of other medical problems or treatment modalities. Keep linens dry and wrinkle-free. When skin breakdown occurs, apply appropriate dressings using clean technique or, in cases in which infection is present, sterile technique.
Teach the caregiver preventive strategies and determine if the patient’s situation is in jeopardy because of inadequate care. Note that the caregiver may have feelings of guilt because of the failure to prevent complications of immobility; the caregiver may need support rather than teaching, depending on the situation.
Evidence-Based Practice and Health Policy
Zaratkiewicz, S., Whitney, J.D., Lowe, J.R., Taylor, S., O'Donnell, F., & Minton-Foltz, P. (2010). Development and implementation of a hospital-acquired pressure ulcer incidence tracking system and algorithm. Journal for Healthcare Quality, 32(6), 44–51.
- A retrospective analysis of data from a single hospital revealed that institution of a pressure ulcer prevention program was associated with more than 50% reduction in the hospital-acquired pressure ulcer rate of 1.8 per 1,000 patient-days to 0.86 per 1,000 patient-days after a 16-month follow-up period. The rate per 100 admissions decreased from 1.4 to 0.6.
- The prevention program required initial admission documentation of patients’ pressure ulcer status using an electronic medical record system, which generated a daily report that was used by the certified wound care nurse (CWCN) to organize care for patients at increased pressure ulcer risk.
- A multidisciplinary team of representatives from nursing, medicine, patient safety, quality improvement, clinical education, respiratory therapy, occupational therapy, dietary, clinical data systems, and administration met monthly to evaluate the algorithm of modifiable and nonmodifiable risk factors specific to the hospital’s population.
- Modifiable risk factors identified in this population included skin inspection every 12 hours by a nurse, patient turning every 2 hours, use of a pressure redistribution surface, management by a CWCN, and patient education. Nonmodifiable risk factors included continually wet skin, poor tissue perfusion, restrictive medical treatments, immobility, and cognitive or psychiatric impairments.
- Physical findings of assessment for potential skin breakdown: Redness and dryness
- Physical findings of direct wound assessment: Size, depth, type of tissue present (granulation, necrotic), drainage; signs of infection
- Type and frequency of dressing changes with sequencing of how the wound was cleaned and the dressing applied
- Response to treatments: Surgery, wound débridement, dressing, medication application
Discharge and home healthcare guidelines
Refer patients at increased risk for skin breakdown to a home healthcare agency to assist with monitoring skin and providing pressure-relieving devices in the home environment. Teach the patient or caregiver about frequent turning and positioning, how to keep the skin clean and dry, signs and symptoms of early breakdown and complications of existing ulcers, strategies to manage redness or skin breakdown, and appropriate wound care and dressing techniques. Use a return demonstration before discharge to assess the understanding and ability to perform wound care.
de·cu·bi·tus ul·cer(dē-kyū'bi-tŭs ŭl'sĕr)
Synonym(s): bedsore, bed sore, pressure sore, pressure ulcer.
Patient discussion about pressure ulcer
Q. I ask a client's Dr. to script flexaril for a lower back spasm and he made it for a drug called zanaflex? I am unfamiliar with zanaflex, what is the difference between it and flexaril 25mg? Benefits? Risks? I got him to order the air mattress and extended bed because client is 6'3" and is already bedridden on my 1st day..try to beat the skin breakdown, already stage I decubitis ulcers. I tried to talk the client into slideboard and lift away arm wheelchair...noway..he wants to walk bent with a rolling walker. He already had a lift chair delivered, so he just goes from bed to lift chair. He refuses to let me bathe him. He can't see, and he has me check his draw up on insulin to make sure it's right. He sends the P.T. man right back out the door after he signs the sheet. Difficult pt.!